Rausa, Louis �o114N of QUEEVBU_'kY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/► '' ,[.7 ,�.�
Name �0011 Case # 'Yee—
Date of CremationL�O
l
Time Cremation Started �0eg"M
Time Cremation Completed ld )
Type of Container /Y r -4-:1
Remarks :
!f �I /�
I
TOWN OP QUEEN$BURY
PINE VIEW CEMETERY
CREMATQRa"
Quaker Road, Queensbury, New York LaSO4
Rhone (516) CrRmatOriuM 745-4477 or If MO answer
Cemetery 745-4476
AUTHOR URT I ON TO CREMATE
The undersigned requests ano authorieas pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oft
LoUis S. Rauaa M
(Name)
(Sam)
,� PO
(Street ) (Cit) ) (State) (Zip Code) �
who died on , 5th ay of
19��
at Home isarneas &bp
(place) (Address)
Hama and address of nearest authorizing cremation : living relative or name of p@rson Mr. Salvatore j. Rausat 20 Oak St. , Hart$dale,1VY 10530
(Naar) RAddrassJ
Rrlatlonnhip to the deceased Son
i
Nam* of leuneral Home Adirondack Cremation A330cfate� Warrensbur ,NY
IMPORTANT s �-�-
I represent that do the has no ac&Mth r be'St Of my knowledge, the deceased 1�'ef.am
P in his ar her body. (Circle One )
i
I certify that for the crvaatiI have the full power and authorisation to arrange
an of the rtmains and to direct the disposition of
the crQ$4ted remain¢, that any persona been removed or may be destroyed, and lag Possessions have either
and save harmless pine View and
from an ee to protect, defend
•nd demands for loss pr damages which may be made and all clams
reason~ st them by
!aE
of or connected with the cremation Of Said agalnremains a5
laims or
hether ufrach kdulent. demands are or A,le not wno ) IY
Same as Above
elative or tregal Rep. and Addr -�
Si creed on bhi r ditbr 2 It3w27-93 e5lJ
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H[,1ERICRN LAND IND . INC TEL :914-683-6264 Oct 27 , 95 13 :55 No . 004 F . 03
OST - 27 — 45 V R I 1 Q4 �S�raTLEXaNDEFR -- 36- A K r= R F _ F-11 ., F, �� .*