Beebe, Donna rrO q+N OF QUEEVBU�KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/4A h1?D P,,
Name a/c s �,� Case # ,f/O
Date of Cremation r2 "02,3 " ate /
Time Cremation Startedr��
Time Cremation Completed
Type of ContainerS77F%o!(4�
Remarks :
J+3� M
19rm
02/21/01 12:02 FAX 541+475+7411 JEFF CO FIRE #1 Z 01
02/21/2001 01:45 5239549 MAYWZ) D _ PAZE 91
Tow KW auendWRAT
PINE V ESW C6MTERY
i
CV404PTUR=NN
Quaker Read, Ovovnsbury, Now York i8664
Phone {3l6) Crematorium 743-4477 or if no answer
Cemetery 745-4476
AurmaRizarsoN To CRanwrz
The andarsIGnob requosts and authorises PCne View Crem*tortum, in
accordance with and subject to its Rules •nd Mo2o ations so
cremate the remains ofl
14
tNaae) (Som)
'70 dA%JV irec�;_Q�tee_�r#� r�. ,Ne+ ir�S� .Qy
(Street) cCftyf (rotate) (Zip Code)
whe died ew61WN, eay of , � M 00
•s-Z1zz-?A;1_y_S_TreeGT-04CfIS/Pbary.Aleh&e} k i�P`I
Ip7ace► (Agereas
Name •Pd address of nearest living relative or rams of person
authori=iaq eremetiori
qaada'��- .04,1 A f,� Xoy 5� 0/ 6JE 1'7 7�1
(Nam• lAddress)
Relationship to the doeoaosd
■ r �irim� w i
Name of Funora} aosel�ftA64#9( _Q, DAPAC's-f oVetQ I PfsMo
t/a/l f r A rr a TTa , - Qy��nr1'bk ry��/�jam./�V
7IIP'Oi1'TfdYT:
I r�sont that to the be� my knewlegge, the dee'aas•d has or
Piss Pie peaolakor to �e nor body. . (Circle Onol
I eortify that I have tho full power and authorisation to errronge
for the croselteh of sne remains and to direes one disposition of
the ersNted rreesns, that %V%y parsprsl possessions have otth•r
been removed or may be doslrnyad, And agras to pr-vtect, dolond
and save hermloos pine View Crematorius froo any and all claims
and demands for loss or damages which may be made against then by
reason of or connected with the cremation of said remains as
Oirec`e4• whether such clots• or demands are or are not wholly
10-Dundlese, Feist, ae Frsvdulene.
c
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Witness) Mddress)
0100
menesv t' Relative a0 LVpal Rep. and Address)
Signed on this dat•s '�'�& 1