Jennings, Robert rf-O%N OF QUEEVBUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name )�o73rhL'C i'i.l Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Containerj'�o,\-,>-J gip4 -Z-j !VLo ill — hp^�
Remarks
1 A6 i JM v
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02125/2053 20:36 518-624-3661 JENNINGS INS AGENCY PAGE 01
02!*25/200-: 121: 45 5IS-636--27J3
SRE4JEK' FUNERAL PAGE '
01
TOWN OF QUEENS®URY
PINE VIEW CEMETERY
CREMATORIUM
t]uaKer Road. Oveensbury, New York 12804
Phone (518)Crematorium 745.4477(if no answer)
Cemetery 745-4476
ALiTHORIZATION TO CREMATE
The and reigned requests and authonzes Pine View Crematorturn, in accordance with and subject
to its Rul,os and R
egulations to cremate the remains of, rr
p �,C + i A S a_i
C-
AME) (sex)
STREET) (CITY) 0 (STATE) (ZIP CODE)
who diec on 1-k . day of c b....__..--. ,�. 20 03
1
1`lillitl tl�Ju MVVIVOC VI 111161WV4 nviny ry11VYYtl VI Iltlllmtl VI WgJaVti 4OLNIV116111y
r r
Relatlo hip to deceased o
Name o Funerat Home 8>ssts>t •oA)«a2u BOMM. Tide.
IMrPOR �
I repro nt�that to the best of my knowledQ J;the"�9cdased hU acerrtaker In his or her
body. CIRCLE ONE)
I cw*that I have the full power and awtfF�F�"'W,prrange for the Cram*lion of the remains and
to die the diilposibon of the cremated remai C that any personal possessions have either been
remove or may be destroyed, and agree to protect, defend and save harmless Pine View
Creme rivm from any and all claims and de rands for ions or damages which may be made
:against them by reason of or connected With the cremation of said rerrlains as directed. whether
-uch CI Ims or demands are or are not wholl�groundless, false or fraudulent,
(WITNESS)__ (AO
(SIGNATURE OF—R-E-LATIVE OR LEGAL REP AND ADDRESS)
Signed on this date, � 1z t,A,,�,,,^,,,
I