Steves, Edna Marie •
TOTIN OF Qf TJ
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director SI/IFFOOD
Name Eine, SteJe4 Case # 7Z
Date of Cremation re b /0 ZUib
Time Cremation Started
Time Cremation Completed
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Type of Container (AiKf w O O L i n
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 Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
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(Name) (Sex)
461s LAkE �AtRE Qia I ti E, 0 LAN,LAN 9 i N G,Jh c l a s' I q-
(Street) / /(City) (State) (Zip de)
who died on (P day of-T EQR a A 20 10
at 14( LARE ( ' R 6nurb . (P1J.9it3C 11 Ia$I 4
(Place) (Address) (
Name and address of nearest living retail-ire name of person a ng orizi c eraatfon:J
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/ (Name) (Address)
Relationship to the deceased 0*A 4529A u GATE R\
Name of Funeral Home " �
IMPORTANT:
I represent that to the best of my knowledge,the. •- <.. (has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or : •.� ircie One)
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.
(Witness) (Address)
, (�l�,z,�. �,(; ,t t, y — rr I .);s C L t �r PR R W)-in
(Signature aAddress of Relative or Legal Representative)
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Signed on this date: 9 /O
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 )6
Revision:January 1,2009