Spaulding. Ruth Ann 1
fO 1v( O9T QUEENSBUR91
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�a , 1)a,7
Name
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Date of Cremation re IIb(0c,r7 I j 7O1O
Time Cremation Started 1; Co 411
Time Cremation Completed 10•1SAr1
Type of Container � I15L+ Trey Ceti F-0RI9 tr)tCsk(
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:
i.,ITl-k Af,3iJ S PAtA,t.pn„1G1 F
(Na ) (Sex)
ZI c ,D1we Qua;As Oki (?68*
(Street) (City) (State) (Zip Code)
who died on n 2�`'e` day of 20 1 0
at 7-1 C.R AILKrDi7d Di ire- S)gte-kIa(egtel I 04
(Place) (Addre
Name address of nea liv' relative or name of person authorizing cremation:
-eal ciz66((NamQ) (Address)
Relationship to the deceased 31Z0' . SZ.
Name of Funeral Home`RPG7it A- Q,IA� e.lel iJ_ j7Al/loti.,p 1
IMPORTANT: `J_ C]
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.(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 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.
(Witness) (Address)
-7.'"edle
(Signatur and ddress elative or Legal Representative)
Signed on this date: I Z1 I Z6 I b
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify: el 42) 41triuth AD
If pulverization of cremated remains is requested,check here
Revision:January 1,2009