Cleveland, Larry Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME: c'E ot A WO_CR. RETURN TIME:
DATE & TIME REMAINS ARRIVED AT CREMATORY: /y/Z3 clop
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
- DAB F1 kqa,
NAME: ---_- G FRN �L EVj%,)D CASE #
TYPE OF CONTAINER: Pt*Alto cot - Pra l0„fi*.�b✓t
PLACE OF DEATH: I I? EZ le PeLV C- 1 Q 166W' Ni• L23ot
ESTIMATED WEIGHT OF REMAINS & CONTAINER 21 S— its'
PLACED IN HOLD:
PLACED IN REFRIGERATION:
DATE OF CREMATION: 7/S-ZDL 3
TIME STARTED: 7 `.n TIME COMPLETED: l
PLACED IN RETORT: 6 MOVED: '' y} %
RETORT # IN WHICH REMAINS WERE CREMATED: trk1 P&,kst
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.
L'CF)
fs7y
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 Coanaatorium,in accordance math and suth(ect to its Rules and Regulations to
cremate the remains et:
Z.-et
e !Iedejj J
( ari ) (Sex)
k OV /AOk Dr. ( �<<.�A.hy. �AJ Zit*
(Street) / (CitY) (ante) (Zip Code)who died on it day of (Li/7 Zt) 2-3at 16 0a(., L T) . '- i 6u
(Place) (Address)
Name
S9and address of nearest living relative or name of person au:hormng cremation:
triMSc"/ /4 y '/c,c> A. l,S,,r..2r.k? J y
(Name) (Address)
Relationship to the deceased�)
Name of Funeral Home f 1 eXred v .Ci' i ( ne .i c .
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,dellirdiator or any other battery operated
device in his or her body. (Girds One)
I certify that I have full power and authorization to arrange for the aernation 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 from any and all dams and demands for loss or damages which may be made against them
by reason of or mourn of sed remains as directed,whether such claims or demands are or are not wholly
groundless,fa
) 5' PZOI crl• Ltici„n4
J, ) (Address)
Relative or Legal Representative)
5lgnea on tnls1 te:
s/!! ?0 6
Disposition of eremateci Hemalns
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check Here K
Revision:4,gyr77- 4