Berman, Virginia J
OF QUEEN,_,50UJKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
Funeral Director ,:); oC._w1=t-ut�1
`•aTe -y) a(r N \ )q �jrsr4- A'% CaseR ) � t
-ate Of Cremation
Cremation Started r)
' ime Cremation Completed
e of Container C44. o�p Y2
remarks
04/14i2004 12:35 17138523697 RICHARD MERMAN PAGE 01
04/13/2004 14:10 518-793-3641 SINGLETON/SULLIVAN PAGE 02
T0VWq OF Vi"sCMstlUltY
PINE VIEW CEMETERY
rM ,
CtwmA•rali um
Choker Road.Queellabuly, Nev► Ywk, I2UU4
P11oo (e10)Creltvpltnlhlls 745-4477(if nu e1�svMerf
C411netefy 740.4410
AU1110141,7,A110N-IU t;ltLgpAA1C_
The ullileroUlmd reyues(e a1Nr auomiaes I;Mle Viuw Cit"ImIuAnau. I11 sucu1Ua11th1'witlt Mld subject
10 no Rhlee NOW RaytwVf le to 0161110111 If1e 10111614011 ul:
vi r�ia 8eselsln
" jFtJAlfilE) Pctaale
(15 (CITY) 18'i AI Cl I Zih C V)
who d(ed on 13 �:>1y ul April
a
(PWC ( IiLS$)
Norm and addNgg of rseareet Mving lelslive Ur 110111e 01 VM9011 aulllorl0tV crelngvCM! �
ft Riaurd $'-rmm 139 Hoyt St- BrOOklyrie MY 11217
R91611 nahtp to NOcseMu Son
Name of Fun"H"__sinvlee . jjm,_y
IMPORTANT
1 represent gut to o»Iivot of Iny IulowletJye, HIS tJecaesed4w wllrtsitel'In we Cr her . .
bcWY. (CIRCLN ONS)
I Certify that I have the IIA pawst and stAlIorla fti to w;jInge far Ule oleltlellon of the nw atIe and
to dkact the di■pootlllon of the cremated remolni,Mt airy►pwoov l pQssutlaw have aitller DW,
removed Of may be destroyed,and 4191 as to Protect.dolelld and saw harmigag Me VbW
Ormnalorivm ttorlt any and e0 OWMIS end defnalWS for Ives w dattlayvs which may be mltde
agGM44 them by rMwn el Or nortrlec e'd w101 the crenlellolf 911124 WOW as dkecWdt WhWW
such dakm or derlMtlh b am or are nol WhWy gtowtdiers,Iaise or Iraudulent.
(VIATME88 (ADDRESS)
(WONATURE Olt RIBATIVE OR LEC4/►L h.ANV ADDRIt SS)
sgnrd on ttlb date; �/ �r1