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Hunt, Edward JI- crnq+N OF QUEEN r ,5BU-�y PINE VIEW CEMETERY AND CREMATORIUM, QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director M-9 F Name � r�wt+�� rl�� Case # Date of Cremation �irt' � � Lq Time Cremation Started Time Cremation Completed 1u115 t� Type of ContainerfiC�� Remarks : M tti S <<S �l7 Mv�6 I �h i i Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,-Queensbury, New York, 12804 Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477 Authorization to Cremate cremate reignedhe requests eqins�and authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to ��,.X..ro1 uv t1a (Name) (SeX) (Street) (City) '1 t (State) (zip Code) who died on day of t/tCe- ?p©CI, at G r F�.��S tic.; , }-1A lJ t •, tic. S ►�— (Place) (Address) , Name and add of nearest living relative or name of person authorizing cremation: (Name) Sc�. c,� �e� ©.�I., 1Z�►e �( s� , ti [ts,6�,`c g 3 \(Address) Relationship to the deceased Name of Funeral Home c�\- IMPORTANT: celel�redfoaciNe impla esent Oat to the t of my knowledge,the deceased(has) (has no pacemaker,defibrillator,battery,battery peck,power nt or radioactive device in his or her body.(CIf cremated remains that any and aulhortzation to arrange for the cremation of the remains and to direct the disposition of the save harmiM Pine Vies,Crematoriumersonal p w have either been removed or may be and ail claims and demands for loss or damages destrond yed, to protect,defend and may be made againsl by reason of or contacted with the cremation of said remains as directed,whether such Balms or demands are or are not wholly m less,fal4e or fraudulent. h n 5-� l-��&ten ��lS ►�� g3S (Address) (Signature and Address of Relative or Legal Representative) Signed on this date: f`f��2f l- !I 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:April 18,2007