Lynch, Thomas TORN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Ou p— K -r--, a —S&NS
Namek U.M►2 L L.Y�I CA Case#
Date Of Cremation 1 ;L-
Time Cremation Started q 0 ✓�
Time Cremation Completed l 3 0
Type of Container All ✓\ j"j 13
Remarks 1
1 to o Y4 4 4,0 t,/�.�
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12/17/2002 16:09 413-443-3324 PTFD CINGULAR PAGE 01
1'L/l 11 6dbL 14:n i �ltl�bt�4-E714' WM. J. HURKE & SONS PNK 02
t`
TOWN OF QUEENSBURY '
PINE VIEW CEMETERY
CREMATORIUM } j
QVSker Road. Queensbury, Now York 1i2804
Rhone(516)Crematorium 745-4477(If n0:driswer)
Cemetery 745-4476
AUTHORIZATION TO CREMA7'iw
The undersi§ requests and authorizes fine View Crematorlum.Eln acaordalnm with and subject
to tts Rinds a Regulations to cremate the remains of
Thomas h Male
fNAM ) px)
i
(.STREET) (CI ( TAFE) ' (ZIP CODE)
who died-on, 14
day of Dece_mbeit 20 02
7 Sandisfie'l Ittoad Il
at New Bos on Nursin C*nbsr Sandiafleld, Mass. , 01253
(PLA } (ADDRESS)
Name and add ese of nodrest living relative or name of person auth4rizfng cremation;
J S osne:
I
Relationship to deceased Nal2ba r
Name ofFunar 41Home:Wiilia,n J. Burue & Some Funleral, Hdnee
v` 1MPORTANT '
I represent that t0 the best of my knowledge, the deceastec!body. (CIRCLE ONE) pacemaker In hisor her
I certify that I hi NO the fall power and authorizabon to arrange for the cremation of the rernalns and
to direct the dis vsition of the cremated femalns,that any personal 00311e6810na have either been
removed cr me be destroyed;and agree to protect.defend and save harmless Plne View
Cremtitorlurn Many and all claims,and demands for loss or damages which maybe made
against them b reason of'or corinected with the cremation of said relmains as directed,whether
such claims or dernands are or are hot wholly groundless, false or fraudulent.
WITN 59
. ( ) . .c(AbDRf;SSy
(8 TU A�LAVE OR 4tQAl"RIP, ADDR♦±S )
Slgn6d on this date: 12/17/2 0 02