Kays, Mary E •
• TOWN OF QQJE1 $ B �lIU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Bc•r{L h,Pr;-v rt
V
Name r6‘,73 Case # q7
Date of Cremation lc/ J 76)iU
Time Cremation Started oJtAfl
Time Cremation Completed•
Type of Container �� ,c1 ; CIZN � riot-(
Remarks :
� J
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:
(I` ►t ) / ( )
(Street) (City) / (State)/ (Zip Code)
who died on / O day of �-C/�ii/c2r , 20/0
et �1� %/� c,K 2> ( � (°A, /�
(Place) (Address)
Name and address of nlarest living relative or name of person authorizing cremation:
E 41? ;;rid ; 6 _ 4/`,7Z-e
Na (�
Relationship to the deceased
Name of Funeral Home 6 ce r Tom
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or - no •. ►:maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Ci •: •ne)
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 of or con ed with the Lion of said remains as directed,whether such claims or demands are or are not wholly
gro, ,false
�i C�%..r � .r/7i 7
/ o,7( i
(S ature and Address of Relative or Legal Representative)
Signed on this date: /or--'/&
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains lows:
Mail to v` /C
-4-1
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2009
I.
I HEREBY EXPRESS TO MY SURVIVORS MY EARNEST DESIRE AND REQUEST THAT ON MY DECEASE MY BODY SHALL
7 RE CREMATED AT PINE VIEW CREMATORIUM, ON QUAKER ROAD, TOWN OF QUEENSBURY, NEW YORK AND FURTHER DO HEREBY
ORDER, DIRECT AND AUTHORIZE SUCH CREMATION.
V f '4
(Signed �n
(Address)�(%• (4'-01:9' '
/a)c ( ee- 1, /A -
i
Witness Q � 1`-
Address 1703 �j60C1-y-IL_( ( —Z )D
LOLS 4/
Dated 1— 94 —D<S`_
d-�
TO BE ENTRUSTED TO THE SIGNER'S EXECUTOR OR NEXT OF KIN
(Return copy to PINE VIEW CREMATORIUM, Quaker Road, Queensbury, N.Y. 12801)