Richmond, James I (-rnWN
OF QUEEN. B U- ��//
�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �lnSmU(`t
Name ma,5 RI Case # j
Date of Cremation Vi�(mf�pr 11 Z061
Time Cremation Started /A
Time Cremation Completed 111`1
9
Type of Container --
Remarks :
I1�rti U !}I� h1y�6 to 0S qjj
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518)745-4477
i 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
-ot A
(Name) (Sex)
�_I `1 C�, I I ✓ //
�� Ir LtZCFllC 1 fC
(Street) (City) (State) (Zip Code)
who died on _� _ day of �
at I 1
(Address)
Name and address of nearest living*relative
/or name of person authorri)zing cremation:
(Name) (Address)
Relationship to the deceased t-
Name of Funeral Home G 1 ti,r��-
IMPORTANT:
I represent that to the best of my Iviowiedge,the deceased(has)or(Chas no)Pacemaker'-.iia&fttor or any other battery operated
device In his or her body. (Circle one)
I cw*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
9rou 4e+0� lens.
..,« (yyitr>ess) (Address)
i (Signature aoa Address of Relative or Legal esentative)
Signed on this date: a 1
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2006