Warnecke, Virginia J - �
• TOTIN OF QUEENSBUIty
PIE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 5 to U^rtle KI- Case # Z
Date of Cremation r` ZO1U
Time Cremation Started
Time Cremation Completed O A17
Type of Container Woo(1 ysleer r Pi4
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 authocaes Pine Vier Cc�torivcn,in accordance with and subject e to its Rules and Regulations to
cremate the ins at:
V 12(`,, 1,0/3pJUC“.
(Name) (Sex)
who died on "'9
7 day of �,�^/1 zu
at f 4 S 42.
(Place) )
Name and address of nearest living relative or name•=person authorizing cremation:
Rail 2 _ wilier-tom � � �_, ))
(Name) ...
Relationship to the deceased Stz. Se
Name of Funeral Home Ai y, v9& - 3 f' r/ (i✓9 4,j/U
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has n tri or any other battery ed
device in his or her body. (Circle One)
I certify that I have full power end authorization to arrange for the cremation of the remains and to direct the disposition of the
remains.cremated possessions have been removed or may be destroyed,and agree to protect,defend and
save hamdes;a,pinViiew matoiium from any and all claims and demands for toss or damages which may be made against them
by •' or watt the cremation of said remelts as directed,%tether such claims or der ands are or ate not wholly
g • •I—� false
�..., .........v ) ? (Address)
(Signature and Address of Relative or Legal Representative)
signed on mis date: //4/lj
Disposition of Cremated Hemains
!hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify: 1-;-/ &4' i Ace/
If pulverization of cremated remains is requested,check here
Revision:Jii y�-2oc4
/8"'1'I 07