Rhodes, Lillian Q
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00.41
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSOURY, NEW YORK 12801
(518) 798.4726
(518) 79:3-9777
Funeral Dirictor ak--/Y5/O�,E
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Cremation Started ,`QQ m
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
crem to the remains of:
A:1w 7h0A_s-
(Name) (Sex)
OCIA /WJAMPtq t-?
(Street ) (City) l
(Stat (
ip Code)
who died on 411 day of D ,CslY) i)1/E- 19 9/
at k 'fl4C. EA- ? Is-6 CpA MI)
(P ace) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
FAlt)h) C)114 A) �51 Alt2 A Z314 1-)Ad ru?
(Name) (Address)
Relationship to the deceased - J 0
Name of Funeral Home 04.(\3$Y'\Q(?1.
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
dire ted, whether such claims or demands are or are not wholly
grow es , s517 fraudulent.
(Witness) (Address)(A�
6341\
(Signature of Relative or gal Rep. and Address)
Signed on this date : l2 /31L 4 f