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Edlin, Stephen G TOWN of Qfy8'uqj PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 3ttr} I ero4- Name �����`' Ec� Case # Date of Cremation _ _ny(,ry I 701 0 Time Cremation Started alp p}1 Time Cremation Completed 3,1qt7 Type of Container RI6 kr({�v CGJ }?oval t , E(.000 CASe Remarks : M prti I: 9rl 110v6 z DCPO Z'3Sp11 Jc P7 , t• ,Jew. 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 Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: / (Nan%).? n (S ) . C3 ✓//7,a iOT �9 ✓set, G�i.c�,�% .�� .�'r-17/--�i 7 (Street) (G"ity) (State) zip Code) V-11 .------- who died on i / day of i ( 201/7 at� � �e .0 �4 , G �?—/ e-c-�j (Place) Address Name/��and address of nearest living relative or name of person a .' 'ng at/ion: //`,f/G� ��-/�7/%1 �T--7 ///7(, ©/Z L A, (Name) /7..pr7-f'' �c-G , , - - ress)_z� Z d , Ji 7 Relationship to the deceased G.'/ Name of Funeral Home C-,>k'rL 7 -'77( c/27ef — �7 IMPORTANT: I represent that to the best of my knowledge,the deceased(has)or has no) maker,defibrillator,battery,battery pack,power cell,radioactive implant or radioactive device in his or her body.(Ci 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 pe . : ... ::-ions have either been removed or may be destroyed,and agree to protect,defend and save harmless Pine View C : :,. 'um • any and all claims and demands for loss or damages which may be made against them by -: •. of or connected I - crema t of said remains as directed,whether such claims or demands are or are not wholly grou r! ,false or r',u- / >, ) F (Address) ✓f/4-i,11 �/ L f7 /'' 1 r l . l — 'i7 (Signature and Address of Relative or Legal Representative) Signed on this date: ///6)%c9/2" Disposition of Cremated Remains I hereby direct Pi View Crematorium to dispose of the cremated remains as follows: Mail to r�-/� — ,`j' Other arrangements-Please specify: If pulverization of cremated remains is requested,check here Revision:January 1,2009