Wabnitz, Roger • uYJiaaLcC. ........
rro OF QUEEM
s5B URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 2ly�J.E-
7Name /1 kJ/7 /1�� - Case # � /
Date of Crematicn C -
Time Cremation Started Q" ,Q
Time Cremation Completed (/ /'* /Q /'/ (M )�/-
Type of Container LA .)9j5 /1-P / 1 e Lk-Or
Remarks :
4d 11n
'2;20,"-998 14:51 3153575501 INL.ET AREA C OF C PAGE 01
TCW OF puEENMAY
pINE VIEW CEMETERY u q
CREfMiT0ltLtJM SS �T I�) ' 16 2 0 G 1
OvaMer Road, outensburv, New Yo"u 12604
Ohone (Sig) Crematorium 745-4477 or if no answer
Cosetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, to in
•ccordanct with and subject to its Ryles and Regulations
cremate the remains of:
Ro AI�v .4Wvt }Z
(N e) (Sew)
u. a T.N. N l 33 v
(Street) (City) (state) tZisa Code)
who died on
f t- .r----h day of Dec�K,s 6.r- 19 T t
(Place) (Address)
Name and address of nearest living relative or name of person
authorising cresations Wt6j Wd P040
(Haws)
(Address)
Relationship to the deC•ased M 0" fr—
Name of Funeral Nomt
I IOOATANT s
I rearf, ent that to the best of my knowledge, the deeeased has or
ws no paCmmaker in his or her body. (Circle One)
I certify that I have the Pull power and authoritation to arrangm
for the Cremation of the remains and to direct the disposition of
the crenated remains, that any personal possessions have either
been removed or may be destroyed, and agree to protect, defend
and soy* harmleez pine View Crematorium from any and all claims
and desonds for loss or damages which may be mad* against them by
mason of or connected with the cremation of said remsiris as
directed, whether such claims or demaInds are or are not wholly
ground false or fraudulent.
" x7 - 4L
` (witness) ZL/-
(Ade�tss,
(Signat a of Rel ive or Legal Rep. ahe Address)
Signed en this dates Q0:,,--.,kt - 201 19 9l,$
TO 3Jed -"3Nnj 63M3be EVLZ--969--915 99*91 8661/61/Z1