Cheney , Donald D Sr. •
L O TINOf. QUEENSBURT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ( JA ( at Sr Case #
Date of Cremation O
ugr
Time Cremation Started ,Q
Time Cremation Completed 3` 0 4
Type of Container (LILA
Rver A9
Remarks :
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5
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 suthactzes Pine View Crematorium,in a000rdsnoe wail and subject to its Rules and Regulations to
cremate the remains at:
Donald D. Cheney, Sr. Male
(Name) (sex)
31 Hudson St . Warrensburg, NY 12885
(Street) (may) (State) (Tip Code)
who died on 31 s t day of December Zu 09
at 31 Hudson St . , Warrensburg, NY 12885
(Place) (Address)
Name and address of nearest living relative or name of person authon:ang cremation:
Ga lt; Cheney (wife) 31 Hudson St . , Warrensburg
(Name) (Address)
Relationship to the deceased Wife
Name or Funeral tjome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,demos or any other battery operated
device in his or her body. (Circle One)
I certify that I have full po ie iir honizatiorl to arrange for the cremation of the remains and to direct the disposition of the
cremated remains, arw possessions have ewer been removed or may be destroyed,and agree to protect,defend and
save ha View Crematorium from any and ail claims and demands for lass or damages which may be made against them
by or connected wIth the aemetion of sat)remains as dratted,whistler such claims or demands are or we not wholly
g ,false or
(Witness) (Address)
Signature and R ' or Legal Representative)
slgneo on trim crate:
January 1 , 2 010
Disposition or Cremated Kemains
I hereby direct Pine View Crematorium to dispose of the cremated remains as toiiows:
Mat 10
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remains is requested,check neeX
Revision:J9dy4