Hall, Patricia TO`lN OT. UEE
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
Name �i}riC
Case a y��
Date of Cremation
Time Cremation Started j0
Time Cremation Completed to S6
Type of Container 0,414e�
Remarks ;
M 4 TN
0A
��c�� ( U: 5DA
Town of QueerWx"
Pine View Cemetery and Cremat D ium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,CremeWum: (518)745-4477
Auttwization m Cremate
The undersigned mWeeffi and authorizes Pine View CIemoorlum in accordance with and subject to Its Rules and Regulations to
cremate the remains of _
�ArhlCjA l`)AII
y ha fJY y rArK &.4r4c u AA) e A/
�►,�1y (city) (S�e) (MI)Cade)
who died on V, r ` day d O e c iP il6.e r 20at
(Place) ( )
Name address d nearest Wire relative or name of person au dwrtrlrq cremation:
its (YI. a' o �tii %P�ln N, - lj l 13
(Neme) ( (Address)
Reledwship to the deceased Cl AU z h r2 �-
Name d eral Fun Nome&?i)A r I- I +�-`' e /�j� ra AJf✓n/ �1� ��—
IMPORTAN P
I represent that to the beet or my knowledge,the deceased(Ius)or(has no)pecernsim.delixNlator,battery,battery pack,power
calL radioectve irmftR or radioactive device in his or her body.(Ckds One)
i cardly that I have fur power and sulhorb allon to arrange for the crematon of the remains and to direct the dispoaitlon of the
cremated remakro,that arty personal poesessiorrs have either been removed or maybe destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all dakrns and demands for lose or damages which may be metle against them
by reason at oonuecled d said remains as dressed.whether such A ml s or demands are or are rat whogy
.,o
Address of ReleWe or Lsgal Repreeer*Mve)
Signed on this daW
Disposition of C rarmttsd Remains
I hereby direct Pine View Cremel orluum to dispose of the crennete'remains as forows:
to I,J i l 0 6,/C
()0--
other arrangements-Please speW-
ff pulverization of cremeted rernekrs is requested,check here
Revision:January 1.WN