Landers, Patricia Ann •
N
TO TI O fF Qi7fl..l L B l..l
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name {r,ci5 Case #
S3
Date of Cremation FILL",,i I Z616
Time Cremation Started /, (U et-7
Time Cremation Completed 3 - 'S' Pr]
Type of Container (ic(LvJ Cis�t—tid of SE-COMO Chse
Remarks :
Mk i- 20 frivv6 Z 'osph
3:0°01
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:
Patricia Ann Landers Female
(Name) (Sex)
269 South Bay Road Clemons New York 12819
(Street) (City) (State) (Zip Code)
who died on 29 th day of
Jan. 20 10
at Her Home
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Donald Landers (Same Address)
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Jillson Funeral Home Inc.
IMPORTANT:
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
groundless,false or fraudulent.
/ 1
S uth Bay Road Clemons New York 12819
(S ture and ress of Relative or Legal Representative)
Signed on this date: 0 2/01 /2 01 0
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: Will Pickup
If pulverization of cremated remains is requested,check here
Revision:January 1,2009