Hall, Mary rO WN OF QUEENs5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
i
Funeral Director����
Name Case # 1,3 !�l
Date of Cremation 3 — a/ — Fjo&
oez
Time Cremation Started 11 °p�/� `
t
Time Cremation Comolete-d � )17/M /
Type of Container�/9/'�,� jq��Jy
Remarks : Z
C�
CZ
� r
-rcD'I.NN DF OL'EEtdSBUP"'
PINE 'VIEW C;ENIET'FRY
GF2EMp i p+?IUP.�
t]uaKer Road Qoeerr5burr "Jew 'c'k
phone r516! CrematoriUfln e45,4477 ;r no en5.verr
Cemetery F 45-44 7 6
AUTWORIZAT;ON j0(:Rij,4A-F
Thp t '�U@r5tt7!'Bd ter�uests Rrd aLfnorizeq i•'ine View Crgmatorium. in aCCOIIVCe with and subj#Ct
to Its P-Jes and Re90dlton5 to Cremate t^e ternarn$ Of
Frrtnali�
t1JAME)
19 CoIumhus 5t r +,7tPC(JOE)
STREc.T) {C!T`)wo io died on !SKATE)
day of 1 C17.
r
ar o$ilf..l:,.it1'n,..8r.g_is�.c�a1 ..M�i�..c�,,�1- Cos►.t.f►L. .... _A: .1�.f1..�S.L1-.�..811ri.dri�.r11
r PLACF I (ADORESS)
Name wid address 01 nearest living ietaltve or name of pefs4n autix�rlxtng cramat/lora
11
.,... ti
-.--U t t i -F, -7ji
�6 to I'd H i I Rd �r !d N k Dab
Re!attonshtp to deo!>t5es7 Daaalt.t x a _. -----.._.._�..
Narne cf runerdi alor-7e Robert
IMPORTANT
i ropresent that to the best of my kraw4dge the deceased h or �;t ns pacemaker in his or hpr
body rCtRCLE ONE)
1 certify that I have the full power and authorization to arrange fur the cremation of the rernalns and
to direct the disposition of the cremated rermalns. that any personal possessions have either been
removea or may be destroyed, and agree to protect. destend and save harmless Pine Vier
Crematonum from any and all claims and demands 'or Ic;gS or damages which may be mane
against thorn by reascn of or connected with the cremation of said remains as directed, whether
such d of dernands are or are not wholly groundless (also or fraudulent
- / ja ►i
i StGNA' E OF RELATIV R LEGAL REP
Signed en t''is
?❑ 7C1i-iJ '.nnllnc r.r�.nrri..r„n �n•�.r rn-» :nT :rn