Lucia, Emaline To rwN OF QUEEN50U-r '
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director N 5 /Vl�) IZ
T e It/Yl Iq U y Ca s e
ace Uf Cremation C)
Cremation Started ✓1/�
' ime Cremation Completed
r e of Container C yk\�,
Kemarks
TCE . LkAotl 4tj D 2 00
PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
2. DATE THE BODY WAS DELIVERED
Nov. ( 1 ) :� 81D3
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
otiv-.�- yle��-
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
Glc�vzV\ & Rvc�rtq - -
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
TOWN OF QUEENSBURY �f •
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requ sts and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
r j I
(NAME) (SEX)
15`� c(� /24- 10 . �,r r-t7l, N is sue`
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 17_day of AjZ5 VC_'<^ 20 63
at
(PLACE) DDRES )
Name and address of nearest living relative or name of person authorizing cremation:
PO ��. uGi
� J
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no pacemake 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 or demands are or are not wholly groundless, false or fraudulent.
ITNES ) S)
(SIGNATU EaTIV OR LEGAL REP. AND ADDRES )
Signed on this date: AL Do 3 _