Mihalics, Thomas J 'TO`i'N J OF QiB U.1U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
;� Funeral/� Director 5fc,t�orC1
Name Ihom,, S t1 cl,c.s Case # 37
Date of Cremation Gov\ rti 2 c , ZD1 U
Time Cremation Started JO' CO
Time Cremation Completed ,o 'M
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Type of Container C u} Ctisl�e,
Remarks :
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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 View Creiaabodum,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
HAL t. MAY
(Name) (Sex)
( 4 LASE �; c 9ie. 4/ mtt p Pb`�T 1\ -)6 aagip i4
who died on 1 day of �AtvuA 20if)
at -l.Etds -fA!L S }lt:S?►TflL c)1\ s ( LLS 11 has a l
(Place) (Address)
Name and address of nearest living relative or name or person aahorizing cremation:
`MAUREEK) VAIVkALAre.S , 4 LAKE �pu5)/A-nnar.7� �oi 11/43T,ii1 I JI
(Name) (Address)
Relationship to the deceased
Name of Funeral Home — -cbe9
IMPORTANT:
I represent that to the best of my ivowledge,the deceased(has) no)r demaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circe)
I certify 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
groundless,false or fraudulent. , /E
(Witness
1�--�- 31 Ct2 n)(1 ,1!)T k k41-G CA) /7 25oiu) /j� i d S— 0
)tW'V- �ti 3Ct 1+4 LAKE . yiz t, 91 brute Poi N7)11
(Signature and Address of Relative or Leal Representative) t
Signed on this date: 11 c9.� I D
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 1,2009