Norton, Elmer rn` +N OF QUEEN5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM,
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name El mew Case #
Date of Cremation �p e l7tl Z3 Z(�G
I
Time Cremation Started A Aiu7
Time Cremation Completed 10 Zo��
Type of Container -- /4' 00'/ CR w p first C
Remarks :
a q1h
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
The hxhdersigned requests and authorizes Pine Vow Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of.
O m r- K l�l.-� n___ 1c,-
6�_� c5 0�, �loa e l (Sex)
i Z
csiree� (City) (state) (Zip code)
who died on 1�� day ot _ 20LL9
at (A x Y-n r-)A Q� �� C7-q '�l Y
(Place) O
me and address of nearest wing rWall or of person authorizing cremation:
or�bvi I53 t451 o2�, C-
O O
Relationship to the deceased y 1 c.atI_ P. 0�• A • - -
Name of Funeral Home �� )�✓�i L �{��LL'1� -
i representttt o to the hest of my knowledge.the deceased(has) (has no) ,dellbrillsOr or any other battery operated
devioe in his or her body. "cle On,
I certify that i have ihtll power and authorization to arrange for the cremation d the rertnai►s and to direct the disposition of the
cremated remains,that any pwoonel possessions hews either been removed or may he destroyed.and agree to protect.defend and
save harmless Pine Kraw Creffelorium from any and a1 daims and demands for loss or damages which may be made against them
by reason d or comeced wit►the aeration d seid remainns as a ec led,whether such dain or dennands are or are not wholly
false or fraudulent.
1. 2-4 St I , ZE i'yL��iL�`
At Aoki!"or LowSigrwd Reprraaraatlwrt ,��,�G X /S-3
on t C ap V- f �, C1
0ha76
Disposition of Cremated Remains
I hereW crseet Mine View Crematorium to d'apoee of the crenated remains as follows
Mail to
Other'anarngeamm-Please specify- c
ff pulverization of Cremated remains is requested.check here x.._—
Hevislon:January 1,2006