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Boggs, Loughran D. own o aeenj itry PINE VIEW CEMETERY and CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12801 (518) 798-4726 (518) 793-9777 Funeral Dirictor Name ,2-e �6? A045�� _S Case No. 02 l _ Date of Cremation 0� —o`, Time Cremation Started /e� Time Cremation Completed / it Type of Container j!� IFV5�9&f L�? ail i (�7/9S.c�" 0/1t- 7r�iC� Z719Y Remarks /� /7 7(/�/ �L,a�Q/1�.C�� © /Y f l /7 /�° 14 IV 17 NO Clod,C 417Q41/v/ DENSMORE FUNERAL HOME,INC. 7-9 Sherman Avenue CO NEW YORK Phone Phone(5181654-928585 IRVING H.DENSMORE.Lic.Mpr. ol? CUSTOMER'S DESIGNATION OF INTENTIONS �/��/'/,✓ /�� "/ FOR DISPOSITION OF CREMATED REMAINS n �,,, Full name of deceased f' �'{�" r � 0j v -, a asevNT Name) SCHEDULED PLACE OF CREMATION SCHEDULED DATE OF CREMATION The undersigned person(s)making arrangements request the Disposition of Cremains as indicated below: [ ] Interment or Inurnment PLA F INTERMENT OR INURNMENT [ 1 Release to: `�J'J — r �• �cy SPECIFIC t A [ ] Ship to: SPECIFIC NAME STREET ADDRESS CITY&STATE ZIP CODE [ J Other: I(we)hereby represent that I am(we are)of the same of nearest degree of relationship to the deceased and/or are legally authorized or charged with the responsibility for the final disposition of his/her body,and that the above are my(our)instructions for the disposition of the cremated remains of the above named deceased.I(We)state that I(We)understand that the cremains of the above named deceased may be disposed of in any lawful manner by the above named funeral home,if said cremains are unclaimed after 120 days from the date of cremation. Dated this — day of 1g MR. MR ) Miss Address Address � m4- (aY(L( City and State Zip Code City and State Zip Code Phone Number Phone Number The undersigned Funeral Director attests to the following: (1) If the cremated remains of the above named deceased are unclaimed after 120 days from the date of cremation,said cremains will be disposed of in the following manner (2) A copy of the foregoing Designation of Intentions was given this day of , 19 to the person(s)who made ^^arrangements for cremation. `� ^"" �'� �✓�ai✓ r✓� rev r 04 Signatu uneral Director Making Arrangments Printed or Typed Name of Funeral Director The funeral firm's copy of this Designation of Intentions will hereafter be completed to show the following: Cam' t N� ;g�a \'` LJ f� '-t: \\,-^- y—Z,,. Actual Date of Cremation ` Name of Crematory 4 Address City and State Zip Code Date of Disposition of Cremains Location of Disposition of Cremams Manner of Disposition of Cremains: Dated this day of . 19 Signature of Person Making Disposition of Cremains Printed or Typed Name of Person Making Disposition of Cremains