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Conklin, Donald i Y ' P .. ` SBU IIYE DER' CEMETERY A �'`../ QUAKER ROAD, QUEENSBURY, CREMATORIUM , NEW Y.ORK 12804 (518) 745-4476 (518) 745-4477 r Funeral Director Name fnS�d . Case # Date of Cremation tce-n 6c.,r' zoo Time Cremation Started q.DU Time Cremation Completed A Type of Container Remarks : rl : 04. v, Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road, Queensbury, New York, 12804 Cemetery Office:(518)745-4476, Crematorium: (518) 745-4477 r Authorization to Cremate The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: _����•lJ�� CotrfG.. '�•�1 t (Name) (sex) (Street) 1�— (City) (State) (Zip Code) who died //on �} s day of N 20 Ot i at k�Csi;>rr+- V "1 I c g - � -&? v (Place) < (Address) Name and address of nearest living relative or name of person authorizing cremation: (Name) (Address) • ' Relationship to the deceased w• L Name of Funeral Home M�rC, `"► IMPORTANT: I represent that to the best of my WxWedge,the deceased(has)or has no)pacemaker defibrillator or any other battery operated device In his or her body. (Ckcie One) I cw*that I have full power and authorization to arrange 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 Crematorium from any and all claims and demands for loss or damages which may be made against them by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly groan ass. or lent. (Witness) ( ) --- � � �So UC-- (Signature and Address of Relative or Legal Representative) Signed on this date: /`�'V 7 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:January 1,2006