Page, Richard A TOWN OF" Q8JRy
PINE VIEW CEMETERYY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorg,,L4),&--47
Name jer/C MHO P*1- Case #
Date of Cremation a - (2 3-
Time Cremation Started ` cZiO /7c/v1
Time Cremation Completed )- " o / '/Vt 1
Type of Container ff rlfrD4A,P ,13-i - /571C, ;;E- A-Tfi(C ,
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM *57
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
cremate the wemains of:
4/M4'D P Cc- � G�
(Name) (Sex)
3D 3 HW )&S b. � J a-ER
(Street ) (-City) (State) (Zip Code)
who died on day of F...Lv-ea.,41-k,.) 19 ( 3•
at (04 t--ni FA-L.5 /4;W/77-C2Z- ')2,&-1Z'S F/fLLS(
lace) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Addy lss)
Relationship to the deceased w/bll �►J
Name of Funeral Home 7 -je&-s1A/6':-/Q_ ,l t�Lj�fT� / 6;
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
as 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
directed, whe.. er such claims or demands are or are not wholly
ground =s� ', r raud%lent.
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_1111Prri nest\ (Addres
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(Signature of Rela ive or Leg 1 Rep. and A ess)
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Signed on this date : oL / 3 _