Shirley, Hardy TO,I I N OJ ✓✓\C _rF V 9?rY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSEURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /YES
PAR /
Name /f Case #
Date of Cremation
Time Cremation Started i /'9/m '
r +
Time Cremation Completed !C 041 1
Type of Container
Remarks: Y
07J 29/1996 22:21 3035419689 JESPEPSEN PAGE 01
TOWN OF UUCEN6DURr
PINE VIEW CEMETERY
a
CREK f OR i UMN
Uvoker Road, Oueonsbury, New YorN 12804
Phone (518) Cr-emotorium 745-0#77 or if no answer,
Cematoey 745 -4476
OUTHORIYf1TION TO CREMATF
The undersaVo*0 requests *r,0 avthor►res fine Uiew Crematortum. 1n
occordance with siW subject to ats f(ules and Regulations to
Cremate the rrMains ofi
y
+.~
Greet ) (C� wy� (6t0tor ( tto Code )
who cl i e d on C2r `_ _�_ _d o Y O f y s?!_ _ 19 .
1 -.qr- J
at jf�- ' '' r- �/i� 4 4.--Z e g f.,ti r_ : 1, a , , /!�. �v3-2
tplarr3 (Address)
Name end ♦ddress of nearest living relative or name of p►rson
authoetztng Creaotiont
' L Q /
(Nacre) r (Address) ,,/ rr� e""fie e,0 D So 06
Relationship fo the ' decrased (-5 S4 --
Near of Funeral HoAt �f, /// --� S/%L _
1PPORTANT8 i
I re resent (that to the best of my' wnobeledge, the deceased has or
a• no paeo�&krr to his or her body. (Circle One )
I certify that 1 have the full power and authorization to a►^rangr
for the cremation of the remains and to direct the disposition of
the cremated r,eeroins, that any personal possessions have either
been removed oI- may be drstroyed, and agree to protect, defend
and save harm) e s Pine use" Crematorium from any and all v1418t
and Oerands fjonn*ct
r damages which may be made against thew May
reason of ored with the cremation of said reasins 0$
ciirrettd, whh iclo)ws or demands are or are not wmol ly
groundless, frakrdwlent.
(Witness (address)
l. 3330 Fvcv r w;t C'a k Yam Dr 8ov (d w Cd ��,
Cris pnature 9V Relative or Legal Rep. and Address)
Signed an this dot} )_ Z-VIY