Greiner, Juanita K •
' TOWN OF QJ E $ B 1R9''
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I'/ 5010
Name Tuh�► ti EN'► f Case # 5 Z
Date of Cremation re �O�uc„ Z , ZUw
Time Cremation Started er0c qt7
Time Cremation Completed
Type of Container 4ciLzrJ ✓oti.�f J first C93L
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:
Juanita K. Greiner Female
(Name) (Sex)
22 T. Owens Lane, Fort Ann, NY. 12827
(Street) (City) (State) (Zip Code)
who died on 3 0 t h day of January 2011
at Resdience
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Patricia Nabozny, 22 T. Owens Lane, Ft. Ann, NY. 12827
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Ma Son Funpra1 ROMP Fort Ann, NY_
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) .4ttro pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or herbody.( i •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 reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
gro diess,false or fraudulent.
, Fort Ann, NY. 12827
(Address)
,t/,(E(� , same as above
(Signature and Address of tive r Legal Representative)
Signed on this date: Jan. 30, 2010
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
Revision:January 1,2009