LaCasse, Lauren M I *. : „
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TOWN � •
F Q LIEENSB LIR Y
Pine View Cemetery and Crematorium
21 Quaker Road, Qrreenshury, NY. 12804-5902
(518) 745.4476
htrp://www.queensbury.nC1 (518)745.4477
Funeral Director:
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Name of Deceased:
Case Number: L j
Date of Cremation: J�.y r 00`/
Retort: w � /
Time Cremation Started:
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Time Cremation Completed:,, If•,
Type of Container: c,_�
Remarks:
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" None of Natural Beauty ... A Good pinre 10
Live '
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
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Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
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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:
(Name)
4 � A Ak �{ (Sex)
P`r /a 6}2_
(Street) (City) (State)
(Zip Code)
A----
who died on .D-1-. day of i a 20 D K
at e,"-f .i ' + A-k -i I —
(Place) (Address) /� /
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Name and address of nnrw living relative or name of person a ,
ry y/� Q ng cremation:
@ame) V, „-- (Address) I
Relationship to the deceased e- '2/1--4-\
Name of Funeral Home C.A.s. ,a• c_
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)o((has no)pacernaker,defibrittator or any other bau
device in his or her body. (Circle One) _— ery operated
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 foss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whet a,such claims or demands are or are not wholly
)....4 avk- ac,,,....._
ground or fraudulentt...i.% 7 .-t,ee M,.._.).,=Fv l
Jl, r Z� 6
,/ (Ad'dress)-
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f::-;r : .1-S0ve
(Sign ur and Address of Relative or Legal Representative)
Signed on this date: 6 /(A) 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,check here
Revision:January 1,2006