Silverman,Dorothy rN T01+N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director V . 8 - ,- 12-
Name O126±rti�5I^L 111 R 4nA y Case #
Date of Cremation C) l3 H
Time Cremation Started
Time Cremation Completed
Type of Container CP Pj 6%y\"0 130\j.,,
Remarks :
l r2N,<x a Ni f��I t �fi c/3sEoF��
Add f/'c-P 0 o P
39b
TOW OF OMENSBUWY
PINE V ILr W CEW-TEIRY
a
cWPOTUR I UM
Quaker Road, Ouelnsbury, NO" York 12604
Phone (518) Crematorium 745-4477 or Lf no answer
Cemetery 745-4476
AUTHOR I ZAT ION T13 CM14ATE
and a.tharizas Pine View Crematorium, in
The undersigned requests Rules and Regulations to
accordance with and o*�ubJeet • to its
creaat• tn.
Female
Dorothy Silverman tSen)
(Name)
440 Bay Rd. Queenabury, NY 12804 Code)
�gtrret )
(City) tStat@I) (Zip
12th ay o f October 19 94�
who deed 4n
at the Fort 11 Hudson Nursing e
(niece) (Address)
of nearest living relative► or name of person
Name and address
authorizing cremation'
Ur. Martin Silverm n Vancouver British CO b
tNaso) (Address)
Relationship to the deceased
Son
Neae of funeral HOAO M•H. Kil
jpMRTAWx the best of MYknowledge, the deceased has or
to
I re resl"t that (Circle ,One)
ho% no pw0e46"r in h i s or her body.
I Certify that I have the full power and auth4iritation to arrange
n of
for th• Cr+ovation of the remains end to•rsonaldirect, the pos*essionssharve( either
tn• Cremated remains, that y P protect, defend
been removed or may be destroyed, and agree Co
and save harmless Pin• View Crewhic�'im fbe made againstlthemlby
and demands► for loss or damages which ma Cry y h remains as
reason of annsuchdcith ore demandsoor* orn of sdare not wholly
directede whether
ground •ss false or fraudulent• // y
7.1
j t0 W � � �
tWibnes ) (Address)
tfiigelature dt A11at i e or Legal R*P• anei Addy
Signed at► tills