Dudenas, Eva rl-nRN 0F QUEENB U1' Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NTEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �cej- / —/?n
Name )r—/J4 C as e #
Date of Cremation 1 f "
Time Cremation Started '6'-"z
Time Cremation Completed a14s- r
Type of Container lay� 5 Ry Y, 'T'/
Remarks :
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11/13/2071 14:33 5136772428 ACKLEY AND ROSS FH PAGE 01
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11/13/2001 11.E6 51Ub712428 ACKLE,' 04D RL;r, FH PAGE Ul
TOWN OF 0UEtN50VRY
PINE VIEW CEMETERY
a
CREMAYOKIUM
quaker Road, Oueensbury. New York 12004
Phone(518)Crom MMium 745-477(1 no anfterl
Cemetery 745rA76
AUTHORIZATION TO CREMATE
T11d undersigned requosts and outhordzes Pine View Crernata(lim. to accordance with anO Subject
to Its Rulft and Rogulaliorts to cmMate the remains of
EVA
(NAME)a LL it (5 )
42 Gurney_- Lane Queensbury NY 128
(STREET) (CITY) (STATE) (ZIP CODE)
who died nh 12 t h day of November zbn
at West Mount 14tal th F
(PLACE) (AODa S)
Name and Addr*U of nearest ruing nVative or norm of verswn avomriztng crernatlon.
ntyipi+.�s ^sckE 11Q tunifty BOMCIN 0riVe_9rm°g,A BeAch.. ri't�t1'5
ReWonahip to deceased Niece
Nernoof Funeral Rome AeklP-X A keS9 Funpral xr,ifi. Cambr AR X
IMPORTANT
I resent that to the best of my knowledge, the deCassed tjLz or has no pacemaker in his or her
body. (CIRCLE 014111)
I certify that I have the full power and sulhortzation to arrange for the crsmahon of the remains arid
to direct the d1sposition of the t;weled temaine.that any personal possessions have either been
removed or may be des"od,and sgree to protect defend and spve harmfa46 Plne View
Crematorium ftotm any and aq claims and demands for loss or dernages which may be made
:Vslnst them by reason of or eenneeted with the cremation of said remains as d1roged, whether
such claims or det"Oda are or are not whollY gmundless.false or fraudulent.
em2v4A. 1414 W. Granada Blvd. , Suite IV, Ormond Deach, FL
("TNE35) (ADDRE38)
� Jk
(Sl NI-TURF OF ftELATIVE OR LEGAL REP.AND ADORE$$)
s 9no on tale date: I I 13 ' 0,1 - ,,,,