Parker, Freida • uYJ�iaL_G ........•
T07+N OF QUEEN4 SB U92 \Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
t
Name ��� ��%�/ ��/l //1 Case #
Date of Crematicn
Time Cremation Started m
Time Cremation Completed
Type of ContainerzL
Remarks:
From DAVIID D. SCAGLIONE, ESQ. PHONE No. : 5W 873 9176 Mar. 1S IM 8:27AM Phi
TOM Or EMSMSOU"Y
PING ')law CENKTURY
cREMATORIU[4
p►iakcr Roads Qa■snsy45Y4477~0�`o i P nv$0nsw■r
phone c�16x Cr An
743-447b
AUTHORIZATION To rnW4 ITEu i ew CPoeitb+"iu■, in
The undueSigned requests or+a autoQitS Rule• and Regulat&one to
accordance with and sub.jeat
0"a met• the remain• oft
a i1--,7J l /� - too")
(Nam.1-16RA NYC
l� r
(Street)
C �t,y) (rtatal Clip Coll#)
09
whn died an ..Jdsy of
at
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tP1�Ce1
Name and address of nearest living relative or nose of Rerson
oatheri2in4 creations
�Nawe� ipdtlrwssl
Relationship
to the deceased x v ., _-
9
Nam* of Puny"al WOOD �
IMpOlt'TANTI the deceased hat or
t rte resent that to the bass °* my kndwl.rcl
has pmaessUpo in his ar her body•
lCssMsMle tins)
full
I ytromaSI*nhofetheerepainsoard toadirectrthetdispositionwOf
fearr the the sr that an Personal Possessions have either
the crvasted reaaLns� y
been removed or mine• �iRw�CrematoriumrOYS'di and sfro■ nny Urte to andteall alsi■ds
and save harmless w be &ads •inst them by
and demands for loss or damages which O&Y 9rwmminl Os
reason of or csrnected with the demands of Said not wholly
dirmated, whether such claim or demands are ar are not
group le f i . er fraudulent.
,
Y tAddrers)
(witness) I
X Las p ure of Aelstive or I wvaa RerP. and Address) f 13
g 1
Y% *ignod 4n this bat!l ,,
MAR. 15 ' 99 UPON) 45,55 COMMUNICATICN N•i14 PAGE. 1
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