Ferrara, Anthony M
OF QUEE9 5B UJJy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4.477
Funeral Director
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Of Cremation
Cremation Started g'Q
- Te Cremation Completed {
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.Tarks ! �
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SIMONE FUNERAL HOME, INC.
105 Lake Avenue r
Saratoga Springs, NY 12866
(518) 584-2240
BODY DELIVERY RECEIPT
(Required by Section 4145 - NYS Public Health Law)
A.NAME OF DECEASED PERSON: 5 UY,n Z
(as it appears on burial,cremation or transit permit)
B.DATE THAT BODY WAS DELIVERED: _ 6-f L 5f, ;) u o
C.NAME AND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAKING DELIVERY:
(Print Name) (Reg.#)
D.NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral Firm Name)
E.NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DI/S�POSITION WHO RECEIVED THE BODY:
(Print Name)
CHECK(✓)IF NO ONE IN CHARGE
R NAME/LOCATION OF PLACE OF FINAL DISPOSITION:
` i i.,i i,� �-:t .�/ (, !^�t 1t« I,i ( � �1/LC-�_Lr✓.Y"�L-v r Ly i t J C 9
(Name) fi (City,State)
(SIGNATURE of Funeral Director) (SIGNA RE of Aerson Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Pink Copy-Decedent's Family
,
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
2. DATE THE BODY WAS DELIVERED
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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
4v,�-
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PE SON IN CHARGE OF CEMETERY
9
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
,
P. 01
DEC-05-2003 09 :32 PM
TOWN OF QUEENSBURY
?INE VIEW CEMETERY
8
CREMATORIUM
Quaker Road Queensbury, New Yo,k 12804
Phone (516) Crematorium 745.4477 (if no answer)
Cemetery 745-4478
AUTHCRIZATION 70 CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules anc Regulations to cremate the remains of
{NAME) (SEX)
(STREET) (CITY) {STATE) (ZIP CODE)
who died on G/� day of
20 v3
f.PI.ACE) {AQQRESS)
Name and address of nearest living relative or name of person authorizingcren-at,on
`� /kWk)i¢,>4
Relationship to deceased Son/
Name of Funeral Home___ f%l"k"
IMPORTANT
i represent that to the best of my krowledge, the deceased h,�o n na ac aker it his or her
cocy (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
removeC o,may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for Ids=or damages whicn may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims cr demands are r are rot wholly groundless, false or fraudulent.
ewe;�t"'r
{WITNESS) (ADDRESS) /Z- G
(51 TURE OF RELATIVE OR L GAL REP. AND ADDRESS)
Signec or this date;_____5 /�ec e