David, Teresa E TOWJ ( OF QQBqJy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/- Funeral Director 3 •M4 -9
Name /_ E Case# 1 9 s�
Date Of Cremation — 1 �.e - 2GC1 3
Time Cremation Started 16 ^a M
Time Cremation Completed 0 A.,
Type of ContainerCIA.\zk oA.0 AA i 12. . 15 P'
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
e • •
(NAME) (SEX)
3.2 /2,g,w6iee, __
(STRE (CITY) (STATE) (ZIP CODE)
who died on /,S day of 20 03
at ,, i4" ra7
' (PLAC (AD RESS) Y
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased 1)
Name of Funeral Home �&-z,--ten — /i d--
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no acemaker 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 e or are not wholly groundless, false or fraudulent.
VIC 4'7 der7
/ (WIT S ) (ADDRESS)
tgefr gze 412744)
I(SIG ATURE OF RELA r
OR LEGAL REP. AND ADDRESS)
Signed on this date: �// a2 00_3
4
SULLIVAN-NUNARAIN &POTTER FUNERAL HOME
407 Bay Roal
Quc nsbury,NY 12804
(518)792-2067
"Customer's Designation of Intentions"
Name of Deceased: _ . '
Cremation:
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
❑ Burial at Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signature)
(Printed Name) (Relationship to Deceased)
(Address)
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium."
Printed Name of Funeral Director Signature of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96
0011.01.0110100111. .I IL J it /1` t. tiutim ..w.