Bruno, Donald Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: �LL� RETURN TIME: k PE
DATE & TIME REMAINS ARRIVED AT CREMATORY: $ 1112Z 2:04
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: p ONAL,0 B QJr10 CASE # 6%
TYPE OF CONTAINER: f toreakl eisck* ( v Lcu
PLACE OF DEATH: cAV IhhCL IJ� L't/JY . fort_ R E bb
ESTIMATED WEIGHT OF REMAINS & CONTAINER (gc As- / 200 g,
PLACED IN HOLD:
PLACED IN REFRIGERATION: 2 ;) p�
DATE OF CREMATION: I Iv)ZZ
TIME STARTED: LOo n TIME COMPLETED:PLACED IN RETORT: ) O MOVED: J,OPnM'1, 2,20 f�p
h ( z/Litt
RETORT# IN WHICH REMAINS WERE CREMATED: fowt-P- PA ell
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE:THE CREMATION LOG SHALL BE RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
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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
cr e the remains of.
(Name) ()Sex)
1.37/ C�,��rj lI// r re d A A/G N '7C)
(Street) (City) (State) (Zip )
who died on �Y11 day of /o f O ?T 20
.„46-t.f4tyip,./005h0-7
(Place) / (Address)
Name and address of nearest living relative or name of person authorizing cremation:
- lJ I- mi) _'1 1 / C4Qi4 Iliai// a . �'1-ec4t L.a/�
AMMO � 7,
(Name) Address)
Relationship to the deceaseed�/ �) �(
Name of Funeral Home C_S-'fi�I f / /�/ J j)!P�-/�1 !Y -k—
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive 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 Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by r or connect cremation of said remains as directed,whether such claims or demands are or are not wholly
grou , se or
/61 7 et-ei sctrc„)AA4 ;‘)_s-qd
(ems)
04 Vie� - iI; 6"?tt. S c
(Signature and Address of Relative or Legal R tative) / .A F/1 G
Signed on this date: / ! CC) 9
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: 1w/f �`C it ",_ J i'4
If pulverization of cremated remains is requested,check here X
Revision:April 18,2007