Wilcox, Linda rrO WN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��� znIEWHY
f i
Name l /,C[,d Case # :J
Date of Cremation
Time Cremation Started xl Pis—
Time Cremation Completed
Type of Container 4,1292 ZLIX
Remarks : '
! / i 1S"A i
r36 AIM �
1
TOWN O (]UEENSI)MY
MINI. VIEW CEMETE14Y
CHEM ITUR I U14
Quaker Road, Uueensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTI•IOR I ZAT I 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 uf :
L-1 r7 Aa. Fey,-,�l�
(Nanlo) (Serr)
-- 91? Lan'JrA t- Ge A-JY
(Street ) (City) (Sta e) (Zip Code)
who died on 17 day of 2000
at Nrsrnc
(Place) (Address )
Name and address of nearest living relative or name of per-sun
authorizing cremation :
I-)-))ha r» l r'nc 9 2 9>1nad4 ad I?I C of l, Grar4,•
(Name) (Address)
Relationship to the deceased_
Name of Funeral Homeeelc�n
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (C.ircle One)
I certify that I have the full power and •aut:horization to arrange
for the cremation of the remains and to direct. the disposition of
the cremated Y1emains, 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 cremat:ian of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address)
(Signature of Relative or legal Rep. and Address)
Signed on this date :
i
"Customer's Designation of Intentions"
Name of Deceased: L I-):1� �A
1 0-
Cremation: ) c I
(Scheduled Date) (Location)
Manner of Disposition of Cremated Remains:
D Burial at *Return to Family
El Entombment at El Other (specify):
I hereby designate the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
(Signalure)
(printed Name) (Relationship to Deceased)
(A"-00)
('Telephone Numher)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placement in a columbarium.
XX),,-P f`2 S,
Printed Name of Funeral Director Signature of Funeral Director gate
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YE110W.Family Copy PINK:Crematory Copy CUSHiTEN Rev.4/96