Peschke, Rudolp A eN viurt v ueenJ u1�l
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD. QUEE 798 UI. NEW YORK 12801
(518(518) 793-9777
�.n.,� E
Funeral Dirictor b ��'�-� �--5�-•
•
dime ► U l�.
f '� / I/ , PESC Case No- _I— l
Dale of Cremation "02 _ /
Time Cremation Started i i
Time Cremation Completed i6 RQ . ��5.� o T�� y
�Go T Birk--
Af
Type of Container a2 ! F,Al /
11cmar.ks M ✓ % , �U�'E
a a ` i/17 /
9111) IL___A__H --- i
( i 1°..0 J
f I
NO' Goo 4,
TOWN OF QUEENSBURY
`--)71, /
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
).., v\<4 tr k A . , ...sc.14 re—
Nam
Sex
a� • 3 act1�
Street (City/ State) (Zip Code)
who died on 13 O day of f De.-e..-- 19 70
a t (�/ 1s ko , j " l'" i
(Place) Address) J
Name and address of nearest living relative or name of person authorizing cremation:
)11\ elT �4C---- Pe-SCtI I -4a2
� � a 2z.23 HAley Pi
( e) (Address) 1 /
Relationship to the deceased 1...)
Name of the funeral home 1A,SOK Oft_ ZAet,, i A a �c
) j-A(_,,
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker 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 irected, wh ther such claims or demands are, or are not, wholly groundless, false or fraudulent.
fitness Sign ure of Relative or Legal Rep.)
7SAq 41é ,car .c--f,-, 1 / 3 LO1Y /(-)
(Address) (Address) l /
Signed on this date c--___, P(.:___ Si a