Hart, Cecil L Sr. \ •
TOTIN OF" Q9VB L 9
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ?ay. 011A7
Name (CCI I klar t Case # 0
Date of Cremation FelDrvari �� I 7010
Time Cremation Started (i 20 Ali
Time Cremation Completed (Q
Type of Container L1c( u(� Pow,r -19;K 1 it t- ( S
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Remarks :
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1 •
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
4 The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
c,rgqmate the remains of•
le t,1 t L. Iravt t r. ►✓i
(Name) (Sex) •
169 Luz ?1. Weevts\owici y tat#+
(Street) (City) (State) (Zip Code)
who led on 16+ (�dayy of c-e7.1arGAG_t"
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—W-.&tissi-4.46-am-t
(Place) r (Address)
ame and add of nearest living relative or name of person authorizing cremation:
Q L. I/f �_
(Name) (Address)
Relationship to the d
Name of Funeral Home t1t.4( at ki
1
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 ere not wholly
groundless,false or fraudulent.
elAt-
(Witnes' (Address)
I
(Sign ure and Addres f Relative or Legal Representative)
Signed on this date: a - aZ— 16
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify. RA-A
_-
If pulverization of cremated remains is requested,check here V
Revision:January 1,2009