Reynolds, Jerry _o.
t .
TOWN OF QUEENSBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C,ta-1zkC
Name Tetzrz.i Ri ti10 4 Case# 060C Ce
Date Of Cremation I "� - ZGOC
Time Cremation Started J \9 A"
Time Cremation Completed oti-N
Type of Container C,14tiskc) �}a.,4,ti) a44)60d AA 15_12/k
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and auCiortzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of.
Jerry Reynolds
(Name) (Sew)
j'jO2 'eJen)cy NO< QJeQr_4b.,tz7 A) / MY() `I
(Street) (COY) (State) (Zip Code)
01/02/2006
who died on day of _ 20
Glens Falls Hospital Glens Falls NY
at
pre* (Address)
Name and address of neereat living relative or name of person authorizing cremation:
Theresa Caputo F.j0a Re e`ocy
(Name) (Address) �C
Relationship to the deceased C�v Wt 4>) 2 ;^-)
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Ci de One)
I certify that l have 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 reran of with the cremation of said remains as directed,whether such claims or demands ere or are not wholly
or
rIfxh,0 5 Wic(Sori 1i4-U(5,
(VYNrtess ��(Address) �,3
j (S ature a ress of Relative or Legal e)
Signed on this date: — . 3 O
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,chedc here XX
Revision:January 1,2006