Barlow, Stanley OF QUEEN�OU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 12804
(518) 745-4476 (518) 745.-4-477
Funeral Director
Fame `Jthn1r ,
I Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container C"rJ J 1 A
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(516) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
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:
(NAME ( )
1 � P
(STREET) (CITY) (STATE) *(� CODE)
, day of 20 0 .E
who died on t�r�1
at u7 Abolo
(PLACE) (ADDRESS)
Name and a ss f near firing relative or of pe on authoriz' g cremation:
& I , ,
Relationship to deceased v v
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no cemaker in his or her
body. (CIRCLE ONE)
I certify that I have the 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.
S) (ADDRESS)
(-SlqtkATURE OF RE LA VE OR LEGAL REP. AND ADDRESS)
Sign on this date: