Gardner, Leititia A L O`Y INOF QiBJ
1.1
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director h3 LTL('1E�
Name �� � Case # (IL
Date of Cremation MO
Time Cremation Started g'w 417
Time Cremation Completed /0. 30
1 D
Type of Container G -I C76c411CI et)v,"rr l �� { krSf CIS(
Remarks :
hftm 1io 411 6%4 (I: ti(MfiLl
4:r (IL
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: '\ //� �:Cc v�ct rle.�
1-c:"ltTitcL_ R • 1,-fir c.�p 1,L.r P1Y1Ge.,
(Name) (Sex)
319 Ira iA;a. oY i- F�t�rJ N`l /A g� (E0r-F n °�,'s''11 me(Street) �(�� J (City) 1 (State) (Zip Code)
who on 4 l day of 7/ N
at aisJ V v 1 �Hio a� L/ 1�i4N )-� � - 05 a
(Place) ddress)
Name and address of nearest living relative or name of person authorizing cremation:
J Oa-PH-H- W. Ken+ i 8 i O 4-1-u n�1 }�n G oorci en S - f
(Name) (Address) &I o v Yr/ /nc� 0 n t�N) 4 7'1-01
Relationship to the deceased n so p
Name of Funeral Home M• D• • K i ) free 1u riP rc-1 nie
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) •/(has no •:maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device In his or her body.(C) -- . -)
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 th261.
tion of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulegt
-;
(Address)
c,......_) •
ignat e ••• - , of •:lative 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:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007