McKinney, Bonnie OF QUEEN BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorJ`»l���(,F_TD
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Date Of Cremation � _ � '2 e) 3
Time Cremation Started L02 SE) rot -An
Time Cremation Completed
T�,p e 01 Container
Remarks d
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TOWN 01= QUEENSOURY 3 1
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMAI E
The undersigned requests and authorizes Pine View Lrematonum. m accurdance with and subject
to its Rules and Regulations to cremate the remains of:
60�JIJIE -"S R&(-, Q,
(NAME) (SEX)
(STREET) (CITY) I (STATE) (ZIP CODE)
who died on I f I ot1Ai.. 25 day of 20t 0 . Ui —
1 e a6" 'W I W R
11 6�1
1 <,
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
�6)ajj. usRtk
Relationship to deceased
Name of Funeral Home �t k1m- �AL, -`�'(r( k4"j 146- {
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
su -plaims or dema ds or are not ly groundless, false or fraudulent.
L�+ �G
(WITNESS) (ADDRESS)
(SIGNATUXe\LATIVE OR LEGAL REP. AND ADDRESS)
Z�S Loy
Signed on this date -3