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Digou, Alexander L O`Y VN OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director M ► OC. Name &EA a/j",06- ��,.,at Case # o� Date of Cremation oZ - o2 Time Cremation Started c�/' ti q'-5— Time Cremation Completed Con !mil • ' f Type of Container 4c�v Remarks : d �f oZo �i-i M r I i I I I1• IV.LD!I 1 -1-� _1("3='I ..1JG IL' I Ii 11,1L.L. I 1- t'-1% 11.1 -- ,gQ .--�?. r8: 6 9x"o75336a1 �I^!GL! IOr� o�LL1°rani aar TOWN bF OVEENSBURY PINE VIEW CEMETERY 8,CREMATORIUM Quaker Road, Queensbury, New York, 12804 Phone(510)Crematorium 745,4477 of no answer Cemetery 745.4470 AUTHORIZATION 70 CREMATE 'I'tie undersigned requests and authorizes Pine View C,ematcriurn, in Accordance with and subject to its Rules and Reguianon5 to Cremate the remains of; (Name) (Sex) ---� �--- i;Strest) (arty (State) (zip) whc died on�.�-.��4 _,�,�_day or-- 4 _20 (Place) (Adore S) Narne and address of nearest relative cr name of person Authorizing cremation: (Na e) (Address) ftelat,onship to the deceased__ _ — Name as funeral Homs, �t IMPORTANT: j i represent that to the best of my knowledge, the deceased has o "- no cemaker in his or her.bcxiY. (Circle One) I certify that I have the full power and authorization to arrange For the cremation of the remalns;and to 'Tract the dlsposltion of the cremated mmairis, that any personal possessions have either been removed 91- -T;.y be deyirr..ye,r, and agree to protect, defend and save ha-miless Pine \re;v CiernatoriLM from ar:y •id all ctairns and demands for loss or damages which may 5a made against them by reason of or r `ir,et-ted with the crernation of said rerrains as drectud,whether 3ut h alaims or demands are or are rrot wholly groindless, false or fraudulent, (Witness} ,.�j (Address) X-171914J Rotative or legal Rep. and Address)} S fined on this dater 1 I I I I CcC 9 ?f,'3": SIP793364L PAGE.013 -_U I-I-; !�:L L,'J. I , I 111 '--!I IULL I UH F 1 U. SINGLE7UH BULLiVM1 SULLIVAN-MINAHAN &POTTER FUNERAL HOME Q7 Bay Road Queen4bury,NY 12804 (518)792-2067 "Customer's Designation of Intentions" A -J Cremation (Location) Ma.ivaez- of Dive6tion of Cremat*J R... ains. x e,.i.i at GIv-xs —4c,_1 LS M Ret-LLra to FanAv D FMornhme-ut at Ej Other (specify)- I hereby dettipate, the Disposition of Cremated Reniains and aclwo-Io4e receipt Of a Ccr,,of this Iona. CxAq AS 0/V ar LA D, cinn V- I 12L "Crem.AteJ Remains -which PhA not have been claimed withmi 120 Jays from the date of cremation may b $ed of, by this firm by place in a columbariurn." Funeral Vir,4vtor S r V. Fune ral cral Dircetor r Data, t —tA) TO BE(,'(-')MPLETFD FOUVWLNG CREMATION AND DrSPOSITION OF CRE!I4AT8rI)�MALNIS (Lo"bon of Crematory) "A,RI IT,Fa%#141 Home Copy "LLOV,IvAMLy C^rr PINKS Cammory Covy CU$INTBN?Av.419 DE C 29 'eLl 06: t2 $197933641 POOE.06 E>CTRR FRGE. 301 6. ,! ulivwiue crsmxtioil,the cremated rettains vt the Mceased,consisting primarily of bone fragments,will he mechanically pulverized t:an uttiid�entiriiebte r:onsisttncy prior to pLacentent in an urn ar other container. a t'itir3s ail ua-ti or conlaint'r suitable for shipment is purchased,the Crematory wiij place the cremated reinaii,s of the Deceased cotttait+er m,hich is not designated for any type of shipmtnt. 8. r.ri the event the uyp or container is insufficient to accommodate all of the cremated rettlttitts of the Deceased,any excess cremated remain%witl be placed Its a secondary container and returned It,the Funeral Home,together with the primary urn or container. 'l, '_rt+'i'e understand and aChIlOwled e,that even with the exercise of re sortable care And the use of`the'(:rtniator)`s bast eft'ort.s, tent possiWt to reccR.:r all particles of the cremated retnains of the utceased,and that some ppartictas may inadvertently bet- or ntnirt icd �•ith ao tides of other cremated retrains remninin in the cremation chatas'ber And/or other devices utilized to pre the cretrrte�1 teinains, L'�'t'e hereby Authwrize the crettat►tary v dispose of soy such residual particles in any Lawful rnsrii deans appropriate. 10. [hjtess 11vte give specific written instructions in this Authorization,the crematiot► prt�cessing and disposition of the remains Of Utcemcd Wilt)not be performed in accxirdanee w0 any particular rtligious or tthnic customs. it. to the e+cnt the cremated iemains o)f the Deceased remain uriclaitned fora period of.30 days,the Funeral Htlme shall give writ' n,c+tict to rn,^us by cwrtified mail at the address(ts) indicated below, f/i'v'e agree that In the event the cretated re►l-11; t7e:€ased remain ulrclaitned,for a period of t�f)dapq after the dgtc such written nvtsFcattou is mailed,the Funeral tioute is a,. mad dirt'cted to dispose of the unclaimed cremated retrains of the Dectased in An)'la-Tut manner it ma) deem apptoprist !i f t1'e rid re to indervinifw, veleaae and hold the Crettiatgry,Fuaet al Homr. their affiliates agents,�a�tployees and a���g}ts,her rntasT. tt r�rr•slit'amid 1!1 ltwb',d'.101 ges,liability or eaust's of action(inc)erdinggattot nE3's'fees ant expensesrmt-of rf0l tan)in rr rectly ion +tb the crt�rr-U6;rn and disposition of the cremated remains of the Deceased,as authorized herein,ar m.laar failure to cot redly idEnlifv ti,e remains cf the Lleceased,dlsciose the presence of any iinpl:i ited mechanical or radioactive deeiCeS,or take posstssion af. tr make per-niane.nt arraagetnents for,the disposition of such retnains. li. is xcefit nt sel.('orih in this Authorization,tto v►'arraaties,expressed or implied,art made by the r,)neral Hor4e,Cr ter*tory,or anv r-.f thtir respective affiliates,agents,or tmpluyets. �l. t,We understand that this docusneot does not contain A Mirplele and det;miFd descri on of ever aspect of the ectinstioc process, P'Ne ac.1knowledge receiving, from file Funtral Home, a copy of the boot, entitled "Cremation Tracts" containing additional explanatory inforenatiun about the cremation process, SIGNATURE OF PERSON(S)AUrIJORIZING CREMATION AND DISPOSITION 1.:+e warrant that all rcrresentations and statements niade herein nre true and correct, and that Vwe have read acid understarti ri,c prv�isions ciStttaiaed io this document,and that Itwe ftsve received the booklet entitled"Cremation t;ac!5". ji1mv ✓Si�nal�tk .----.. ventveM N^4 j — F.'At one 1 'i peg,^r}o 11 Add ttssJ — Address -_-----_,_Tel.No. — Sind CNr SWIt J- L'C %AVI TNIE'SS Date:�_ ------- , --- - t99a Sd Mantztlemcnt L.F' ?Wk; r­.,Hems eeo, eot.7,r.w;w re.. aEC 20 •02 c+E:;zG 5187933641 FACE•©9 + TOTRL FRr,E. 10 't.�.