Campney, Dora a
TOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM -y-
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ���6'�� '5010,
Name L.2i�+J} C;Pjo PNE �"I Case 11
Date of Cremation
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Time Cremation Started L
Time Cremation Completed L � tj -
Type of Container i[f°t�.Gidl ��" ✓/ } r � �
Remarks :
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12:45 01:21i197 JILLSCN-FUNERPL-H0r£_ 518 499 10 AGE-02—
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TOWN OF UUECNSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
Guaker Road, Uueensbvr- y, New Mork 12804
Phone (518) Crematorium 74Z-4477 or, If no answer
Cemetery 745-4476
AUTHOR i tAT ION TO CREMPTE
The undersigned -equestS and authorizes Pine View Crematorium, in
accordance r,ith and subject to its Rules and Regulations to
cremate the remains of:
(Name) (Sex )
SStreet ) (City) (State) (Zip Code)
who died an Z S T __day of
at
(Place) (Ad" ress)
Name and address of nearest living relative or name of per,san
authorizing cremation: ,cys/,--
4 -0
/27
{Nave) (Address)
Relationship to the deceased Is7e)n
Name of Funeral
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in tics or Her body. (Circle One)
I certify that I have the full powrrr and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any prrsonal possessions have either
been removed or may lie destroyed, and agree to protect, defend
and save harmless Pi11e View Crematorium from any and all claims
and demands for 'loss or damages which may be made against them by
reason of or Connecter: with the cremation of Said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witn ss) (Address)
Craig ature of Relative or Legal Rep. and Address)
Signed on this date : � ��� ._--
V 4
INSTRUCTIONS UPON DEATH
I, Dora Campney, wish to instruct those who will have to
make arrangements for me upon my death as follows :
i. I would like to use the Jillson Funeral Home
in Whitehall, N.Y.
ii. It is my wish that my remains be cremated.
iii. I wish for burial to take place in a cemetary in
Whitehall, N.Y.
I make my wishes known at this time to ensure that they will
be followed. I have discussed these plans with Judy Goff of
7 1/2 Montcalm Street in Whitehall, N.Y. who has agreed to
see to them for me. My son, Paul Campney who lives in
Easly, South Carolina, will be unable to handle the
arrangements due to his own health problems .
Signed V Date
Witness Date
ex
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Witness Date