Millington, Jean rf-OTVN OF QUEEVBUr�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ��cr/914
Name U'E/g/y Al lAj/� lulu Case #
Date of Cremation 5 — al , 0-360 f
Time Cremation Started ��ydO&M +
Time Cremation Completed cJci 41Ml
Type of Container j, .P ,64g
Remarks :
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45'411Y2
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM /
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of no answer Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of:
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(Name) (Sex)
(Street) (City) (State) (zip)
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who died on 3 day of 1''�1 i+'0"C'd 20 0 l
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(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
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(Name) (Address)
Relationship to the deceased S i
Name of Funeral Home 121��.An/ 4` l�Lllll�lY
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the cremation of the remains and to
direct the disposition of the cremated remains, 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 cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
(Signature of Rel ' e Legal Rep. and Address))
Signed on this date: `rY �� .1
REGAN &DENNY FUNERAL SERVICE
0 QD*K Raw
Qw=Aum MW Yak 12804
(519)792-1114
"Customer's Designation of Intentions"
Name of Deceased: EA t, rdf,,(
Cremation: tviA;-,,�L/4 v16,ov
(Schedule Date) (Location)
Manner of Disposition of Cremated Remains:
I Burial at LCIVS r-ALJS UWIC ',014— El Return to Family
El Entombment at El Other (specify):
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I hereby designate, the Disposition of Cremated Remains and acknowledge receipt of a copy of
this form.
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(Signature)
(printed Name) (Relationship to Deceased)
6'1 8 T—A $—I
(Address)
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7 V,;L - t4,2 4"R
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may he disposed of by this firm by placement in a columbarium."
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Printed Name of Funeral Director Signature of funejOtOrector Date'
or Undertaker or Undedake-r
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated Remains:
K, (Manner of Disposition)
(Location)
(Date)
Name of Person Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW:Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96