Ferrill, Richard Jr. r'_O` N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '5" /'. t7i4k
Name am)'LL Case #
Date of Cremation
Time Cremation Started 3 e)
Time Cremation Completed �, /Y AA
Type of Container 0140_�)
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Remarks :
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hon
TOWN OF OUEQ4SUU12Y '
PINE VIEW CEPAU'rei- Y [�
&
CREMATORIUM
Quaker Road. OueeiisUmy, New Yuik 12UU4
Phone t510) CFeit)p1mium 745-4477 (il nu answer)
Ceinetery 7,15-4470
AUTI-10RILA'1 ION '1 U C;I tEMA I E
The undersiyned requests and aulhudzes Dine View ciumutunuin. in accuidance with and subject
to its Rules and Regulations to ctemale the temains ul:
"'J /n fi��
(NAME)- (SEX)
A' // .Z �O/
(STREET) (CI•IY) (S I E) (ZIP CODE)
who died on ay uI zet-9l 20
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or tame of person authorizing cremation:
Relationship to deceased
Name of Funeral Home s
IMPORTANT
I represent that to the best of my knowledge, the deceased has o Itas 11 acemaker In his or her
body. (CIRCLE ONE)
i certify that I have the full power and authorization to arranye (or the cremation of the remains and
to direct the disposition of the cremated rernains, 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 rernains as directed,whether
such claims or de ands are or are not wholly groundless, false or fraudulent.
O7
( T ES�S) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dale:_/��i L z,
SINGLETON-HEALY FUNERAL HOME
407 Bay Road
Qucensbury,IVY 12804
(518)7934459
"Customer's Designation of Intentions"
Name of Deceased.: �l..r.,c^�� ,!y y/ 2
Cremation:
(.Scheduled Date) r (Location)
Manner of Disposition of Cremated. Remains:
❑ Burial at XReturn to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated. Remains and acknowledge receipt of a Copy of
this form. J ``
(.Signature)
0-IAyip ,C 1 A �,E/z+2i I/ !�✓!
(Printed Nam (Relationshi to Deceased)
q 4,'
(Address)
, I8z
(Telephone Numher)
"Cremated. Remains which shall not have been claimed. within 120 clays from the date of
cremation may be disposed, of by this firm by placement in a columbarium."
S� z-/a e
Printed Name of Funeral Director .Sig afore of Funeral Director Date
or Undertaker or Undertaker
TO BE COMPLETED FOLLOWING CREMATION AND DISPOSITION OF CREMATED REMAINS
Cremation:
(Actual Date) (Location of Crematory)
Disposition of Cremated. Remains:
(Manner of Disposition)
(Location)
(Date)
Name of Person Malting Disposition .Signature Date
#9 WHffE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96