Hoysak, Mary rrOrwN OF QUEEMs5BU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK lN04
(518) 745-4476 (518) 745-4477
Funeral Dire ctor ,le9 �0,/y - / lc 0-,�rR/04c/
Namem O Case #
Date of Cremation
Time Cremation Started L M
Time Cremation Comoleted p2 P/ M
Type of ContainerC R-096hRP ,3 A?D od6j. -p/ -2r-'-
Remarks : C.
1
TOWN OF QUEENSSURY
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 cremate
the remains /of:
(N e) (Sex)
(Street) (City) (State) Zip Code)
who died on � day of
at. �� �r� L XV
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
A7
ame) (Addre
Relationship to the deceased v
Name of Funeral Home `
f.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle OnO'
n u•,. . . f:7.p ,l�l:i
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the-.di.9p S11 Xoh cf'f
the cremated remains, that any personal possessions ' h' Dither
been removed or may be destroyed, and agree to protect, defend-and
save harmless Pine View Crematorium from any and all , claims . , n
demands for loss or damages which may be made against them .'<by
reason of or connected with the cremation of said remains' as
i ted, whether -such claims or demands are or are not wholly
groun ess, als� f audulent.
(Witness) (Address) IlW/
"(_slgnatxfre of Relative or Legal Rep. and Address)
Signed on this date: