Randall, Ann r/-O74N OF QUEENs5BU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director j�lTUu�c� �S
Name A IR1914aAki , Case #
Date of Cremation r 30
Time Cremation Started
Time Cremation Completed
Type of Container v4 M D �3
Remarks :
JUL-29-2004 07 ;24 AM BQBHUESTIS 518 963 8009 Ili
P. 02
I W ILIN I-Lf49RAL F FAX NO.
Jul. ae 2W4 01.06Pm P1
CWN OF DUEENSAURY
PINE VIEW mrITERY
CREMATORIUM
Quatker Road. QueemlOury, New YON 12804
Phpne(9 tgl Cnmatorlum 745-4477(1Fno arr,swer)
Cemetery 745.4479
AUTHORIZATICN Tq CIIEMATE
m4 undersigned requests and authoNges pine View Crernatorium,in Ift"artce With and subject
tc its Rules and RepulstfOns tO cremate the remains of.
{wlrutic) (B
( (Cl )
{� A (ZI
who died on-_ s duty of
X at—.h��•T f vPSCA.) 1P5,,o�UG 14n,U
Nan11 address of nearest living reladva Or name Of person authorizing crgnu den.
RefatiOrtattip 14 det:eaaod �cyr
Wire or Funeral Norma k l L M e n- Fu N E w A L
IMPORTANT
I represent tho to the best of my knowledge, the dscsiasad hM Or 11112 W PW0fN*or In his or her
body. (CHICLE ONE)
I certify"W I have the W power and authorization to arrange for the efontabon of tho roman snd
to direct the disposition of the crernated rerrWrts, that any personal possessions have either been
re( MV40 OF may be.destroyed,and agree it protect,defend and save harmless Pine View
CramaWum tram any and all claims and demands for toss or damagas whI&may be made
against them by res on of or Wmeoted with the erematlbn Of sold remains as dkWed,whether
such,eleimc or demands are or are not wholly groundless.false or fraudulent,
( NE5 ) (ADDR -- -
(SIGNATURIj OF RELAXIVE OR LEGAL REP AND A DRE55)
Signed on this daw--- I z !Pq