Harrington, Wilhelmina ritYWN OF Q7 [ c8QIy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director R1; F,,, �cnn
Name l^`
i fv.,n< dt^c n 1V., Case #
Date of Cremation F2o i zoo
Time Cremation Started V Il) ,
Time Cremation Compleed jb :vU
Type of Container /LciLcuA ?��� r g F trim C•>5.
Remarks :
.
11,
It
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 a es Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
orerrate th remains of:
(Name) (Sex)
11 ACti5tiVt �e . ,,�1AAW a .1 �r ( 3Z
(Street) •(-� (City) /�I,� • (State) (Zip Code)
MR died on 'Z "' day JhiU,Q11.`( 201 U
1-4.d4:tilot Z\e'll wex.17—TTiki
(Place) (Addr
Name and address of nearest living relative or name of person authorizing cremation:
t where.( 16q (ktvet'o(.c t g.�.(ceu kukt /144
(Name) (A Tess)
Relationship to the deceased ( •5011
Name of Funeral Home GLUG€� 1 J1e Pr 0)'K __
IMPORTANT: J
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle 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
ground ,fa
(Witness)
or fraudu '. � r�
( � / (Address)
(Signature a
ndAddress of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: W th t- -6) /WU-a,44`� .
If pulverization of cremated remains is requested,check here 1/
Revision:January 1,2009