Casey, Frances OF QUEEN,5BU9�y
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURy NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director_ S / 1�
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Date Of Cremation
. !me Cremation Started -
' tme Cremation Completed
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Remarks'(
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TOWN 01: QUEENSBURY i
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Giernatununr. in accordance with and subject
to its Rules and Regulations ttooJcremate the remains oL
CC 114A 6 1 6—�
(NAME) (SEX)
� C� h �P�'ot1�'�u, C_c. l� •. . � .Z�� Lf
(STREET) (CITY) (STATE) (ZIP CODE)
O
who died on C� ' day of ' /�1z3E!'Z 2063.
atI��clS
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased DAtt6I./i—E—te—
Name of Funeral Home ���/V,* - �---
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed,whether
such claims or1dem�wands areILor are not wholly groundless, false or fraudulent.
4A== 1 / ' aZ — I I
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: Mhz)0 �s
Town of Queensbury
Certification of Cremation
Pine View Cemetery and Crematory
This certifies that the remains of. Frances Casey
were cremated on September 10 20 03 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death September 8 2003 Age � -
(Month) (Day)
Funeral Home Sullivan Minahan Potter Registered No. 375
ZI-
(Authorized Signature)