Masseri, Angelo John H
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PINE VIEW CEMETERY AND CREMATORIUM
• QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745.-4.477
Funeral Director,,, fey
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Time ati e Cremation Completed c * f�
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
/9l �l% i r elm -- (Sex)
-cvte 4AeZ.,
(Name) Sex
(Street) 2 (City) (State) (Zip Code)
who died on 3o day of il 4— 20,2 6
at � %%'',/C`(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
/2/%4 d..4-co-7�-i iv_4 aO1 - �':��5"&�/ t i '`�i ; for a-4 , /17
(Name) (Address),
Relationship to the deceased] G{1 j�////
Name of Funeral Home (2?-L '��''�4 /Z'/.4,..e)4 7f a 7-
IMPORTANT:
I represent that to the best of my knowledge,the deceased(Mespor acemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I 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 -- • of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
g • • ,false or - •ulent.
• laG fitness) g ,04 ,) /1 4,/f7 24
(Address)
LilnArli
(Signature and Address of Relative or Legal Representative)
Signed on this date: 'cX.c-c .3 0, z 00 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to n -+
Other arrangements-Please specify: / %G� /f�1- y TO J� fiN / (?,1 1-ucc,/ �,,'lil
If pulverization of cremated remains is requested,check here x�x
Revision:January 1,2006