Caldwell, Frances o qtiN OF. O UEEP�5B U .
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12844
(518) 745-4476 (518) 745-4477
Funeral Director STA f-6-
Name rri'to (.S GI Case # (M
Date of Cremation
Time Cremation Started
Time Cremation Completed
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Type of Container •.e<< -e� CRAUEp�,�
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476,Crematorium: (518) 745- 477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of.
'T-RAtAc� c �AI�o��c�.L �EmAi�
(Name) (sex)
JS4 PL= 1 L.L 0 LTO Ni LA
(Street) (City)) (Statef Zi
who died oIn/ in day of �0\)E M Q E R -20 �j
at 15' " PC TTE R ,N 1 L L Rddrefis V. . &\i TD t i _A N n l N ,-n
Name and address of nearest living relate name of'eison ed[horizTng14cm(w A , CAL - cx C LAN9(NG3-h
(Na (Aaldressj (J
Relationship to the deceased t"A
Name of Funeral Home f2�c �R
IMPORTANT:
I represent that to the best of my knowledge,the deoew (has) h no) maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
( )
0LTUt,,I L/AN (�fNG,11 � la%-I�
nature and Address ofliblative or Legal Representative)
Signed on this date: D�Oct
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy:
If pulverization of cremated remains is requested,check here 4-f—
Revision:January 1,2009