Hossann, Helen (rO`1 N OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
l i Funeral Director_Pnsmcr(
Name r �;, r rlbSg�l�n Case # Sq
Date of Cremation ;� »��t�- � l Z00q
Time Cremation Started
Time Cremation Completed to` 00Adl
Type of Container
Remarks :
M �ti An �iv�6 `� �O �►�
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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) 745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine Vlewtorium,in accordance with and subject to its Rules and Regulations to
icrrema/te the remains of: �/✓�
(Street) (City) (Star) (Zip Code)
who died on l �y p f 2 Q`(
at 11 +i A-vc,—e C--t',�.rl., N 7
(Place) I (Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
RelationsNp to the deceased ly.:+:
Name of Funeral Home
IMPORTANT:
I represent that to the best of my lax wledge,the deceased(has)or�pacernakar,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and authorization to aminge 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 Cremator um from any and all claims and demands for ions or damages which may be made against them
by reason of or con d with the cremation of said remains as directed,whether such claims or demands are or are not wholly
ground uduW t. _ ,(
o ef-t A v-l-e crM.r.t t tx ( � i,�� /U, f ���(�•J
(witness) i (Address) ----
S",-,A--
(Signature and Address of Relative or Legal Representative)
Signed on this date: `_
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
OtIw arrangements-Please specify:
If pulverization of cremated remains Is requested,deck here
Revision:January 1,2006