Losee, Betty rrOl+N OF QUEEVBU.�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director&ff,CM
NameZ,ic.-- T-1[� Case # 4 '�
Date of Cremation
Time Cremation Started !L Yd /M 1
Time Cremation Completed `(�ja i �� /!� r
Type of Container G' l✓` ��S�b� T � ���
Remarks : -�
�P q3 Alm
` /�� 411101
01/30/2001 09:49 914-331-1482 KLEIN a KLEIN, E5QS PAGE 02
!.a 121EF ''-NEPAL. r-10'F G�., ��. Jan. 77 1LI 1-4'1 F'a
TWIN :)F+OUEENS®UP r
'!NE ';15'v%1.,EUIETERY Gf
°Eyie,`bP,l l.M �j Mt
'Maker Road. +.,.eenSr.�,- ti'Ew YorK ��:67d `'
'►tole t:i D)Gr6ts�Cnurr 745-447' ,,,f no answErl
C;!rrtdren 745-4476
AUTh7RIA70N TO CREMATE
The undersigned requests and out izes Pine N,',ev,r Cremstcr%m in aerardaMe kv;n ano ss:byoot
to its nubs arse Requravons to cremate me rgTa.ns of
BETTY . _OSEE FEMALE
(
If s, Cf+tt'e n
,D. +o
{ f ITY) (STA ) ZiR CODE.)
*m died on _ ,.r,rrr caY of 3Af'"IIAfi J 20 01
st GLEU FALLS POSPITAL, GLENS rALIS. MY 12801
( A—r.E) (ADDRESS; — --
Norio and address of rea,reest,ivinq rawuve or name of person authorizing crernatior.
Lem _S /!l /G -ice it 069�.1,_cr -b....0, , -
Re(atteronip to dsceasod �^.�_
Name of Funeral Home .B, KIVAER FUNERAL HOME,
UPORTA14T
I reprewt that to the bast of my knowledge,the aeCeaseo t3—j 04z;�aoernaKer r his or her
body, (CtRCL6 ONE)
i aertthr*a t t*w the No pevmr and suchorivstion to vrange for the cren'ation of the remains emu
to direct the disposition of the oremsted remains, that any persoria' possessions have either b*w
removed or rney be destroyed.and agree to protect defend and save harrntesa Pine NAG*
Cremetoriurn from any and a!I claims and cemards for lose cr do',m*990 which may be meads
a9ai!1tt fern by rsaeor.of or:ornbcted with the Cremation of saiC remains as directed whether
ah oisime or dam rids we or are Act who!'ry grcundless.false or fraudulent.
( , }
WGNATURE OF RELATIVE GR LEGAL REP AND ADUREW
S oned on this date;