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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director
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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:
Irene Riegler Female
(NAME) (SEX)
258 Aviation Rd. , Queensbury, NY 12804
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 4. >'`I day of OC7 20 03
at pt,oy;,v7 • r. /112(yi , AIL(
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Raymond McCoy, 196 Hinds Rd. , Ft. Edward, NY 12828
Relationship to deceased Nephew
Name of Funeral Home Alexander-Baker FH, Warrensburg, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased tipar 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
Cremator um from any and all claims and demands for loss or damages which may be made
a'gainstAem by reason of or connected with the cremation of said remains as directed, whether
S such.dlaiims or demands are or are not wholly groundless, false or fraudulent.
(WI SS) (AD�DDREESS)
(SIGNATURE OF RELATIVE OR LEGA EP. AND ADDRESS)
Signed on this date: 9/i O,03