Gorham, James OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM`
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director BREOC Z
Name V �.n�S 60j" Case # S�
Date of Cremation ?IVC04'r z00
Time Cremation Started (` Id Q�
Time Cremation Completed 7, Z0 fh
Type of Container
Remarks :
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Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and autottes Pine View Crematorium,In accordance with and subjW to its Rules and Regulations to
the remains of•.
' iry1,,") C-)o r I�c�irn MQ IL
(street) (C8Y) (Soo) (zip Code)
who died on 70 day
yo'f D P t`F m 209
at Qj�n-1 �a I L� Y C�7��i � VnS �a 1 I� ).1�►'
(Place) k( )
Name and address of nearest Nving neledve or name of person au#xxa*V cremation:
(Name) ( , (Address
Relationship to the deceased U-) T�
Name of Funeral Ho 9721: �P PP
IMPORTANT:
I represent that to the best of my lawwledge,the deceased(has)or no maker.delbilidw,battery,be"pack power
cell,radioactive Implant or radioactive devios In his or her body.(Circe )
I certify that I have full power and authorization to arrange for the cremetlon of the remains and to direct the dispositlort of the
cremated remains,tits any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine awnworium i� and ell calms end demands for loss or damages which may be made agakW them
by reason of a the o�said remains as dlrec N4 whether such dekns or demands are or are not wholy
« c77
(witness) (ems)
e- ci� 41
(Signature l of Relative or Legal RepresentaWe)
Signed on this date: a l b f�
Disposttlon of Cremated Remains
I hereby direct Pine View Creff iaDrium to dispose of the cremated remains as follows:
Mail to
other arrertgemertls-Please apecifY:Y� ' Gt 't`h f /7kk
ff pulverization of cremated came its is requested,check there X
Revision:April 18,2007