Loading...
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 : Arlo � 1 ,,4 i 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