Bump, Elise TO q+N OF QUEEVBUI1 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director m `i
Name r � � � � �� Rum P Case # d1go
Date of Cremation P - ( '"1 7
Time Cremation Started
Time Cremation Completed �' 2' 'C30 n' � '
Type of Container C_ IRI ROCL('C-1 C,A-S-C aAR) t 011�y
Remarks :
/��i4i N ,C3y/�i��R o�! 1 / : �a � •m �
i1 �i I 1-0 P. m
11 /l
I
DOWN OF 1JUEENSUU"Y
DINE VIEW CEMETERY
A
UIiEMII I Oli I UM
Qual►er Road, Oueenabury, New York 12904
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT)IOR I ZIIT 1 ON TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains or :
--I- Q v /U �o
(Name) (5e")
(Street ) (City) (State (Zip Code)
who died on day of _ 19 _
(Glace) (llddr•ess )
�r
Name and address of nearest living relative or name of person
authorizing cremationt
v I F'4 ov/Kz!
(Name) (Addroaa
Relationship to the deceased
Name of Funeral Home M. B . Kilmer Funeral Home
IMPORTANT3
I represent that to the best of my Knowledge, the deceased has or
has no pacemaker in his or tier body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
grou less, false r Fraudulent.
(W ess) (Ad ess )
c
(Signature of Relative o - Legal Rep. and Address)
Signed on this dates