Washburn, Pamela L O Y YN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorm 13 1) KE R ,
Name PA/Vk 'F'k9 W 42 J /y( Case# / n
Date Of Cremation of - I [— -)—Qp
Time Cremation Started C( C)AA
Time Cremation Completed
Type of Container(3-0-1o► Ch4* I( I' 1A '1 1 � 6—
Remarks 7
ct KLI)'1
1 a 35'P►
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02/04!2003 00:53 6239549 MAVNMD D PAW 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
CREMATORIUM
QuaKer Road, Oueensbury. Now York i2804
phone(618)Crematorium 745.4477(it no answer)
Cemetery 7464476
AUTHORIZATION TO CREMATE
the unowsspned roquaets and authorizes Pine View Crantstonurn,in accordance with and subject
to Its Rules and Regulations to Cremate the remains or,
IV to
(NAME) (SEX)
(STRSET) (CITY) (STATE) (ZIP COD )
2-1
who died on r ►' day of / d F„^p}k_„„. 201
at Ir ir S twe e-
(PLACE) (ADORERS)
Name and address of nearest living relative or name of person authorizing cremation, jP w i h
/ZWIV A�;, 10,�e-�l;lY.rvNc�d�r/r•�►���a a.
Relabonshlp to dscessed fA T hG t�
Nome of Fun"Home /iqg
NillOPtTAIiT
I roprssant that to the beet of my knowledge,the deesased AU of peowaker In his or her
body. (CIRCLE ONE)
I cw*that I have the full power and authorization to arfangf for the erentstioh of the remains and
to dlfe0t the disposition of the cremated remalrta.that any personal posseselons have either been
removed or may be destroyed,and OF"to proud,dellow and aye harmless Pine View
Crematorlurn from any and all clairra and demands for logo or damages which may be made
aQa1Mt them by mmn of of Connoted with the crerMatlon of MW fell no a directed.whether
owh claims or demands are or we not wholly groundless.false or fraudulent.
- 10
(" 9j �M�RE98) /S- L/f/d/� 0 y✓ � 9�1
(SIONATURE OF R GAL REP ANO ADQ )
x Signed on this date: LO-T
t '
wn-IAM WIt Wd &0: ZI £0OZ-be-93d