Bennett, Elisa TOUN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name P196�J) gj!='�( Nf- Case# Qj
Date Of Cremation
Time Cremation Started Q �'L
Time Cremation Completed - \„ (��
Type of Con tainer(nP Nzd 3Cvk-z-r) ,-2,tJ6 /A Y•a
Remarks
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FEE-10-2003 05 :54 PM ABRAMS,-LACAGNINA 206 628 0483 P. 01
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FEE-10-03 MON 12:36 PM CARLETON FUNERAL HOME FAX;8187461689 PAGE 2
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
ac
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 746-4477 or if no answer
Cemetery 746-4478
AUTHORIZATION TO CREMATE
The-un'dbrailgned requests and authorizes Pine View Crematorium, in accordance with
and sub ject.to its Rules and Regulations to cremate the remains of:
' 4RNg�t'6t
F1i�§a.P,1fxLa,�lti&tC Fil�t,ls►
I11i�rne) (Sax)
4 Nortb. xch L& __�� Queensbur_y _ New York 128M
pi set) (City) (State) (Zip Code)
who died.an 7th day of February, 2003
9t' 4.'North Church thy, Rneengbu y, Now York
;:()lace) (Address)
Name 4,4eddress of nearest living relative or name of person authorizing cremations;
Fra_r Ge► Lacagnina 1709 3ft1h x"nueI 9ogt1'i Soattia, Nash 98144
(4Vatne) (Address)
Re{aflon*p to the deceased aieter
Nam:.&.7uneral 'lome .
IMPOTANT:
! =.kor
erit that to the best.of my krtowled e, the deceased has orp in his or her body. (Circle One
I cerity: � att 1 have-the full power and authorization to arrange for the cremation
of'the<ritnains and to direct the disposition of the cremated remains, that any
persorillo5sol95[ehS have.either been removed or may be destroyed, and agree
to pp'rot00t,;defend and save harmless,Pine View Crematorium from any and all
claims 'a:ric# demands fot loss or darnages which may be made against them
by i"sdn df or connected' whh the cremation of solid remains as directed,
whethee',such claims or demands are net wholly groundless, false or fraudulent_
S
,g 1709 36th Ave, S. Seattle Wh 98144
(0fl ne s r (Address)
1709 36th Ave, S. Seattle Wk,98144
Sid at r510f Relative or Legal Rep. and Address)
Signed on this date;