Blanchard, Joyce TOrki OQVPINE �'�S
VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD,
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director
Name
Case#
Date Of Cremation / X—d
Time Cremation Startedt �'
Time Cremation Completed
Type of Container (,V d c
1 5TcASe
Remarks
,09�
an ,pi
5 S,
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:
c T. El-4 Pun dn 6 Perna.lA--
(Name) Sar+f1 Glans Fo.lis (Sex)
Lamp -H�tret_ k e 1J 'kr)C la Ya K
(Street) J (Cry) (State) (Dp Code)
who died on "Z 3u a day of fYl 10 e r 20c3
at j larnpA'n+cr Ave- 'IOUe ', ,Net)yrx 1L. 12 -ZV
(Place) J (Address)
Name and address of nearest hying retire or name of person authorizing cremation:
9l71,(rsz_ V.CCAOL
(flame) (Address)
Relationship to the deceased-00-Lt ant er
Name of Funeral Home u(XLL d.'b,iSC1.6,C Funi CQ. VYiL
IMPORTANT:
I represent that to the best of my ivrowledge.the deceased(has) • 41;)-•,-- �detibror or any other battery operated
device in his or her body. (Circe One) -
I certify that I have full powar and authorization to arrange for the cremation of the remains and to died the depository 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 Orenhalaium ban any and ail claims and demands for loss or damages which may be made against them
by reason • • •, _-- m
,with -creation of said remains es directed.whether such claims or demands are or are not whogy
•
groundless, "fr-
qv,
: ) Il La.p,ydAe �fi erns 6u r yi N y 12 Yd`i
a, OIL, • e
" (- . :, -and . .--i of Relative or Legal Representative)
Signed on this date: `-2-I?L' `C5-1-
•
•
•
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please spedfy:
If pulverization of cremated remains is requested.dnedc hare
Revision:January 1,2006