Keener, Ralph T01KN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /1 /�/Vj,4FX
Name / // ��/s�� Case #� �b
Date of Cremation,-'r--- �z N
Time Cremation Started
C� I
Time Cremation Completed
Type o f C o n t a i n e r C&j2&"D is 7-, c1sf-t9yc- `��AC 1�
Remarks :
0,4
r
7= Of OVEENS611RY
PIKE TIN CUIETERY -
•
CRONTOUIUM
Quaker Road, Queensbury, New York 12601 4(z
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
W11 RIZATION TO CRPATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its
Rule; and Regulations to cremate the remains of:
Ralph G. Keener Male
(Nam*) ------------- - - -- --- (Sex) - ----
20 RIVERSIDE DRIVE, SOUTH GLENS FALLS , NY 12803
(Street) (city) (State) (Zip Code)
who died on _ 14TH _ _ day of MAY 19_95
at LEISUREARMS NURSING HOME, TROY , NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
JAMES R . KEENER RD 1 BOX 24 , WILLOUGHBY RUN , ROCHESTER , PA 15074
(Nome) (Address)
Relationship to the deceased S 0 N
Name of funeral home M.B . KILMER FUNERAL HOME , 136 MAIN ST. SOUTH GLENS FALLS , NY
Iii WANT:
I represent that to the best of my knowledge,the deceased has o has no pacemaker in his or her body.
(CIRCLE ONE)
1 certify that I have the 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 Cremlatoriuml, from any and
ail claims and demands for loss or damages which may be made against them by reason of, or connected
with the cremation of said remains as directed. whether such claims or demands are, or are not, wholly
groundless, false or fraudulent.
X
(Witness) (S 9 ature of Relatt r Legal Rep.)
(Address) (Address)
Signed on this date
TOTAL P.02