Hewitt, Henry Jr. 1o`NIN of QUEE BU
-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSB RY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director_ '-DL) l= E: Imo'
T e P�- tI EW ;—r'T— Casey
DaJie Uf Cremation _ Z
Cremation Started
�e Cremation Completed / 0 ""nn
' Y pe of Container��� ��, -�� .4 A
Remarks
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SEP-23-03 TUE 12 :50 PM TOSSING FUNERAL HOME 802 773 5467 P. 03
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Next of Kin :tn verm9nt.
cuorl Vlrual Iaanti�loat.iuJx Not
)eecri�y1�l.caatty#I►Iet}►ode Vrsd to C'orifirm,ldenti&4tion (a.tl•, pltataq pha. raer., watt�v/)
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S��K� II• �'Ct OF-COMMO I'e Q NG"RANt bM�Ir"►q'11
havi fit deolirtt►d to Mr►na xd/Jtti�icoi�n+x
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tFr n w.er1'1�it.v.'I/Ob
SEP-23-03 TUE 12 :50 PM TOSSING FUNERAL HOME 902 773 5467 P. 02
� . . rWrs Y_1
TOWN OF(WICN95URY
PINE VIEW CMETtny 3 CREMATORM.4
ONAker hoed. Qutelonab=jry, N%w Yaru, a 7804
phena(6t 8)CramatOrlUm 74544710l nv an6wer 013rnetery 745-44 7b
AUTkQR"'FION TO OREMArF
The:uncferytgnod?*quests and author►=ue pine v o* Crematorium, in Acoordunc#with Arn;1 t;ubjsa to its
Rubs or=d Regulations to Cromat*tha r#mgir s of
Hee�rY_ Hewitt Ma L e
1„ .254 ;State Rte. 24 Granville, NY 12832
lt3arer ( ityi
(t3tst*! ILA) .
who 4lad vn 2 3rd
---.,.._.. __..._ �...�._.,,.__...�.._...._day vf..___sg�� �rnbez•_..--...._. ;'rJ Q�_—
it lens Falls, Ho�p,�tai• ,�r.�.�??@_� Y
�(P.tecel (Address) 9,a.1�L..�
Nadi@ snd eddrase of n"i'681 relative Or rant®Of Persor.Avth(xLVnp Stremallon
hxr s. Bat I Ta Q cla r V, 1,._GS�I
( Lln�p) (AQclribs6
kelatonshlp to the decaasca
Nanlb of Fun(vel Ht MO_4vj.r K� 19�i�rrh..tt�ia.,.. .Fair. xaven, yr
05'743
IMPORTANT
( repr$Wnt oot to the beet Of my knowlsdpo,ins ao"wo r es b Arty paoems)w in h.e or hor body.
(Circle Ono)
t;C'*(fify that I have the full powor and authorltptwn to arroge For pie arern*ton of tno remains sr4 to
daft f the dlapti0an of the cremitled rpmains, that any personal pwitlegolamO hawo sithes Dean ntmoved
or ma prat
y be daMmyed, and eg(ea to sck de(end and save hermloss Pine View Clem Porwrn trap env
erld all t?leln $ and d4ma? S for 10" Or damages whicr; may 00 rnt,de Against gum by r*t+som of or
connected Wth the ore pVon Of said ratra{ns as dlroued,V014ther Such Garm3 Pr dornendd tire or are not
VA04Y QIOtt'wteas,MISS or fraudulent
t neee) (Andress) i
S 19 Ature 61 R441ive of Le a1 flap.end or*eesji
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