Hess, Norman L •
TOWN OF Qq3'uRT
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
j Funeral Director /14 Kk(), 12
Name NOr 4'1V Re Case# 00Oci / 6--
Date Of Cremation > — CC
Time Cremation Started l l 3 ci P ,/1-‘
Time Cremation Completed 3 0 c7
Type of Container eq4 j2 3 4 1 ) A , (744
Remarks r
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tIN CA 4 S � �1 1447 ,t :) 9/. 1 C) PA4
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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:
A/C1 t-I/-}iv . hi 5� /V/ L L=
(Name) (Sex)
LI ?A/z . LA LAC 'J/ A y /
(Street) // (City) (State) (Zip Code)
who died on f7 day of -J/}u/t%1/Zl 204,e
at !( Me-i C/ Al J35V1//-Jc'p 11-6 (. f t
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
E 1/ �} G D"ZJ v he/z/z/_r re.1,S N Ai J
(Name) (Address)
Relationship to the deceased_T 04 L-1(//i L n
Name of Funeral Home > ,�. Unrk �f tV_ �[. . Mark.3tic.
2310 Saranac Ave.
IMPORTANT: ', ;, ; ,� 1 2310 Saranac Ave.
I represent that to the best of my knowledge,the decea � )or(ties tRitalglekmIgtpr,q1013419tor or any other battery operated
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 pnccessions 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
groundlesslse or fraudulent.
mil` .�3. 'Mark,3ttc.
Q aranac Ave.
(Witness) Lae I'aCid, NY 12946
Oi1C
( ignature and ess of Relative or Legal Representative)
Signed on this date: ✓A N J 2 b C �,
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to _
-9i'6 1 AM-Plost-d ent'e7 4Qt.�3. (lljctrk.3nc.
•a&V aeue,reS 012? —
Other arrangements-Please specify: Lake Placid NY 12946
If pulverization of cremated remains is requested,check here t"
Revision:January 1,2006