Frasier, Geraldine rrnq+N OF QUE
EN,5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
N a m er,ej Z4��j/3( � j�, C a s e # �-If$
Date of Cremation / 1 — l3 — add j
Time Cremation Started 9,1d
Time Cremation Comoleted tG$' A try t
Type of Container0, of 0, C d ' -
Remarks :
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11/08/2001 15:27 5185854475 WILCOX REGAN PAGE 01
r 'h
TOIJN OF Ol1E 48BURY
plW- VIEN CEMETERY _
a
CREMATORIUM
Quaker Road, Cueensbury, New York 12804
Phone (318) Crematorium 74Z-4477 or if no answer
Cemetery 743-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Ping View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of'
,� t. � L.
(Name) (5eH)
/ewAaQue 'dy' - ZA
(Street) -1city) (State)
(Zip Code )
who died an _ day of A
at
1(;Z(= ASA zlim-C )cll-r A/az.
(Place) I (Address)
None and address of nearest living relative or name of person
authorising cremations
(Name) (Address) OF
Relationship to the deceased
Name of Funeral -Home
INPORTRNTs
I represent that to the best of my knowledge, the deceased has or
has ea pacemaker in his or her body. (Circle One)
I certify that l have the full power and authorisation 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 mad* 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 Relative or Legal Rep. and Address)
Sig d on this dates