Schoelank, Richard H TOWN OF QEq i
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1115
CLA2Y
Name 01c1,0,r4 -1\oe„ Its,gK Case #
Date of Cremation td9roAr7 71 Z0/b
Time Cremation Started Oc
Time Cremation Completed !O_ 10 40
Type of Container a,cl poa C(Z/aV *0 t ,r (rjp
3fi
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)
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(Street) (City) (State) (Zip Code)
who died on 31�- day of %M A/EA4 12y 20/o
at A C. - u1 ItLey,v 44/cL PL.4 -,P N.y. /2-9 V e
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
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(Name) (Address)
Relationship to the deceased V/
Name of Funeral Home Ii f3 CL-4 1'L-!L 1N - L-4/(' /'44G, AY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hes) pacemaker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device M his or her body.(Circle )
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
grour�tle�alse or irauduierrt.
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(W (Address)
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(Signature and Address of tive or Lai Representative)
Signed on this date: J!3-N. 3/, Z o 1 o
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify: /'1 CJCEF l4 y
If pulverization of cremated remains is requested,check here XX
Revision:January 1,2009