Secoy, Teresa 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
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Name s e G01) 're— Case # 5 �
Date of Cremation /2 .'O /
Time Cremation Started /Q
Time Cremation Completed
Type cf Container ��� CC�S O� 1 h � � Y �r ( �/^La04./`�
Remarks :
> % /St P,
10/10/2001 15:20 5188543600 MCCLELLAN PAGE 01
08/23/2000 0-9:10 518- } .-417d 1 U "��f:E`P:hih:� rfatic �z
(TOWN OF QUEENSWRY
PINE VIEW CEMETERY
8
CPEMATORIVNI
Quaker!Road,Queensbury, New York 12804
Phone(5181 Crematorium 745-4d77(if no anativer)
i Ctmetery 745-4476
t
AVh1ORIZAT(ON TO GREMATIE --
i
i
The undersigned requests and aufh*rizes Fine View Crematorium,ir:accordancm with acid
subject to its Rules and Reguta!ion to cremate the remains or,
?'*AeVA
(NAME) (SEX1
(:STREET) (G Y) (ST TF; (ZIP CODE)
Y '
who died on /� ( dtit of I�iG►'c? Q ZU 4 1
---
(F'IAGE► (ARESS) ,' S
Warne end av(iress o►nearest Ih/Ing�elative or name of persart taulhorizing cremation:
Re)at:onahw to deceased—
Name of Funeral Horne +/
IMPORTANT ,
t represent that to the best of my kn -Medge, the decreased tins r h r► acemaker in his 01L h '
body. (CIRCLE ONE)
t cer:ity that i have the full power ian�authVrtzmiicn to BrrStlqe ira me Cremation of the remaih5
and to direct the disposition of the erPMa.(e i remains. that any peraonal possessions have oq-'erp erlT a
bear.removed or ma4,to derflroye(f,(and agree to protect,derertl arid sevb haflinitss Pine:Viwh
crematorium.trcin any arld all clakn}and demands frx loss or:ta;ria;�es which Irta be made
agalns!them t)y►easo;n`or eonnedted with the Cremation of said rerneins as directed,whether
such claims or•e1orvarsd::aie or are riot wlwlly ground) s, false or Erauevient. "� i`I �`
sd
f�t-4 SS) (AC I;f2E55) —�--
(St 1E c)F R.F-LAT hLy
OR LEGAL. REP.AND*RFSS
Sign,on this date: 12
—
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