Hance, May fo� T0114N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I
Name Yl l/y Case #Tb
Z2� o-7
Date of Cremation /;
Time Cremation Started
i
Time Cremation Completed 3,
Type of Container 1%» `"' a1121 d5el 4:7 7 �y
Remarks :
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12,'2 1 A 3 13: 02 'CC,16 345 1508 KAL ANESTH PC Z002
DEC 21 '93 01;_:1'5PM PT&T FPX 9015PF P. 1
�iI
TOWN OF QUEENSBURY
DIME VIEW CEMETERY
a
r-PEMPTORIUM
Now yij,(
t.c;1q3 Crematorium 745-4477 or If no answer
Cemetery 745-4476
at% and authOe 4 i,14 pine Crematorium, In
',:C -,n !-:d subject to Its ku16S and Rq;"Igtions to
" *main% C7$ z
N (Sam )
�
ii a I!MAr K Nnq Center J Ct G r a n va 8
r t, (State) ( Zip Code)
-2 _day of Deceraber 993
at 311T3CK Nursing Cente- Granvi 11e ,N"i 2 85 3 2
0 s s
Name &no aL10--vws of I'EarfSt living rtl&tive or MaA# of person
Y
lr&nsnip to the dec9ased
Name of Funeral H000-1- , &- Potter Inc
ropr*#Ivnt that .cj t,,# d! -t dv�#ased��ha; or
has no pac*nakor 2n his or nel- wady. (C.i One)
I certify that I have :he full power and &uthcrl eat ion to arr-Ongt
for the cromatiOn OF this P-6kai,", &If` tZ direct "tie el'""Ition Of
posSrSTIons Move either
the cr^oeated remairts, th-*t Ar-Y to protect, defend
boon removed or may be cestv^Opedv &nd- f-Gr*C
and save harmless Pine Vlevv frce any and all claims
and demands for lZbl;., cr damages which may be made against then by
Fleason of Oi- CoOnact*0 tl,# crawat eCn of said remains as
directed, WmQtmqr SwC?N Ur are or are not molly
geoundlQss, false or- fraudulent,
(Witness)
a/OL pp,, __