Bemis, Freeman P j.!
TO`14N OF Q9B U I
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director j))AEa
Name rittri.c;\m` S Case # "11
Date of Cremation relo 11 ) 70ic
Time Cremation Started ' /
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Time Cremation Completed 11: (JU J )
Type of Container ��Luvul
Remarks :
Mt N ��� 9:117ni,
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9.)
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:
Fr. - pvie-ilis �1��'
( me) TTi ,3&L . (sex)
— G, r /UV / 2-Pd/
(Street) (City) (State) (Zip Code)
who died on clay of f 20 /0
atihr—re.
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(Place) / (Address) i
Name and address of nearest ' ' relative or name of i '•: cremation:
l�r _
�[ ,� 1 r� / ! _ S�ncr z /c -s1-s C/=
(Name) (Address) 7 l
Relationship to the deceased \\ l V) [ L I `'� /
Name of Funeral Home r� U ��i J _ f-''(J„o L P/7.
IMPORTANT: ^mott
I represent that to the best of my knowledge,the deceased(has or(has no" ecemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.( 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 remake.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 connected with the cremation of said rema`in) directed, demandss as whether such claims or are or are not wholly
ground l / U - ( A7'( / L
v
(wltnags) (Address) � //
X m ri2
(Signature and Address Relative or Legal Representative)
Signed on this date: 2 22 / C,
Disposition of Cremated R ins
I hereby direct PinenView Crematorium to dispose of the cremated ' as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:January 1,2009