Katezel, George ..Y.iass.aL_G .... ...
70%N OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /1a")G-
Name C /7� �.G Case # q:a /
Date of Crematicn z2 —le `2�
r
Time Cremation Started / / 1?4 a /M
Time Cremation Completed�� / 1 m t
Type of Container C1lt,2& M zaby
Remarks :
,41,41'N
I1 i/ /)f'h(q /�/1
/ 7-,
TKW1 OF QUEENESURY
P I NE Y I Ew CEMTERY
4
CREMATORIUM
Ouaker Road, Queensbwry, Ng" York 12804
Phone (5181 Crematoriva 745-4417 or IF no answer
Cemetery 745--4476
AUTHOR i ZRTTCl+I TO CREMTE
The undersigned reaue'Sts and authorizes pine View Crematorium. in
accordance with and sub}ect to its Rules and Regulations to
cremate the realms of:
^arr:T get,-.al Ma, ip
tNaeey KS4x)
1o02 13e*dle Hill I-Rd. , Easton, NY 12185
tStreet) (City) (State) (Zia Code)
9 i rt o f November 19 98
Wn0 died Oft day
St. Tatars Hospital AL'St�nyr N�
at
(place) (Agtlress)
Name and address of nearest living relative or name of person
sYtherizing cremation:
$�becca"K9atzesl 1002 'Beadle hill Rd. Bretoll YT 12105
(Mare) (Address)
Relationship to the deceased Da�ii;ntCx
Aro er Tansza i FTOMR• Inc.
Name of Funeral Hame
INMRTAKTs
i th&t tea the best of my knowledge, the deceased hat aw
has hts or her body* (Circle One)
I certify that I have the full pgvwer and autherizatian to arrange
For the cremation of the remains and to direct the disposition of
the cremated reoasns, that any persQnsl possessions have either-
been removed oY may be destroyed, and agree to Protect, defend
and Sav: harmless Pine view Crematorium from any and all claims
and demands for loss or damages which may be made against then by
r*oson of or connecteb with %he cremation Vf said remains as
directed, whether such claims or demands are aT are not wholly
,ground est, false or fraugulent.
t ' Mess) r'ess)
V'--Z—��K h4oy'�
(Signature of MWIlative or tegal Rep. and Address)
Signed on this d a t e: 9'—. JJ