Perreten, Lucy zO%N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
t
Funeral Director ( h. M
Name Case # dL��
Date of Crematicn
Time Cremation Start ed1,,' ' tJ/M
Time Cremation Completed �iA( �
Type of Container
Remarks :
/1,,91'N a&)1 X a__9 oil ���d oZ &M
i
TURN OF OUEENBOU"Y
' pIM vlEw cEl+tErElav
R
U 14LPiA FOR I UM
Quaker Road, Quevnsbury, New York ltg04
PI l;i101 C, wo"Of", ►vR 74y- 4,477 , I f no ofis►+s,
Cemetery 743 -4476
AUTHORIZATION TO ChEMATE
The undersigned recquvxts and euthorizvo pin. View CrematoriuM, to
aceordancv with and sub.lerz-t to ats Rules and Aapulations to
cremate the remains of ,
LSj.11a K Parraten
(Name)
Pleasant Valley Infirmary Argyle NY
tlatirlet ) (City) (State) ( Z..-11p C0110 ) _
who died on _ 11th -_ _ .. day of May
wt Pleasant Valley Infirmary, ArQylg_ NY 128Q�_
i P l ace) (Fiddre s s )
Name and ,address of nearest living relative or name of per-sot,
authorizing c••emat1on1
?A7Au
Mamie) (Address) _.. ..
Relationship to the deceased Son
Name of Fvneral Home M. B. Kilmer funeral Nome
I M"RTANT>f
I represent that to this boot of my knowledge, the docraova has or,
has no pac9mak9r in his or her body. iCircle One)
I Certify that I have the full power and 'authorilatidn to arrange
for the Crvmetion of the remains and to direct the disposition of
the Cremated remains, that any personal possessions he-vo oithor
been removed or may be destroyed, end agree to protect , defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or demages which may be made evainst than by
9-e009n of or connOetwd with the crematiol, ur Paid ►-Irmeins as
directed, whethvr such claim$ or deltands are or are not wholly
groundless, felt# or fr-akidulvnt .
W t ddress )
igipnature o Relative or Le al Readdress) — —.•'_
5 P• end
6ignod oi+ this date >I�' �2