Gaikas, Velta TOTIN OF QUEEN,5BUU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 74 5-4477
Funera 1 Di rec tor_ :N
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=ace Of Cremation Z
T Cremation Started T) it/I
Te Cremation Completed
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�e�arks
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03/22/2004 10:49 5164991050 1:LLSON qL µ(me PAGE 82
TOWN OF DUEENSBURY
PINE VIEW CEMETERY
6
CREMAroRjum
Quaker Rued, Quee*1sowny, New York 12304
Phase(518)Crematorium 745.4477(i1 no answer)
Cemetery 745.4476
A:)THORIZATiON TO CREMATE
he i,naarsiyn�requests and autnpritst Pine View Crematorium ill aiccoroance with and subject
to its Rules @,,a Fteguia•junq to(;.emate the Terrains or
(NAME) f�i�•-��G�'
(SEx}
is•rR t=T) (clr } (s TE) ( 1p C DE)
who JO(I .HIF�Kc!ti
day Of 20,0V
PLP.CE' (ADD�Eq
Name and aggress of nearest living relative or name of person autho•iZIng crematron�
M�,•�trrl ,ua, � 4Jprc�,rq�� nlb.M
Reia�;onsh,p t,�ccceasea_ �iC�
Nam4 Of F;;nera. Hornet_
IMPORTANT
f rep,4aent that is the C-st of rry knOwlapge the deceased a
body. (CIRCLE ONE; tth _nolpiiCfmaicer Ir. MIS or her
coniiy that + Mare the tu'i cca,er and authorization to arrange for the Cremation
to Of the romaln■ and
to direct the disros.tron of ne cremeted remains, that any Enonaal
i'aMaved or may be destro�e nd agre4 to protect Cefend ana save harmless pine View
Y P possessions have either been
Cre rum from i3n 'rns ana demands for 43S Or Clairnages wh!�h may bS made
am.(
a
i3inst m.(tar re art 1 Qnnerted with ilia Cremation of said remAiins as directed,whether
uch clt de or s
r are not wholly groundless. to so or fraudulent,
{VJ :LULL Id
I NES }
GNAT URF OF IRELATIVE DR LEC3Al EP�N DDR �049(rC may" G71
Signed on this d8te'����� �
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