Bizek, Ann rrOgtiN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director AO\-5t 1Q
Name 19 N&I n . 1 l F�C )N Case #
Date of Cremation �2 �L `z, _
Time Cremation Started - 6 LJ
Time Cremation Completed 2 —3 5 P--21
Type of ContainerC'v-\-\;2�) G(-.tAl2d AA,4,1 \),—
Remarks :
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i
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�)F QVEENSBURY
r114E VIEVV CEMETERY
11
CREMATORIUM
RQ ;1, Quftnshury. New York. 12604
i✓n� ne t518) ';rern:�tcxi��m 7 45-"77;if no answer)
C;ermtery 745-4476
A,VrH0Ri/-ATJ0N'r0 CREMATE_
fi@ undersigned reoue Vs and atrth%nZe,.,- t'inu View Crematorium,to act-ordance with and subject
to its Rules and i•;eyulatrons to crPmete the remains�ok
(RWE (SEX)
Z2 & /
(Sl El) (CITY) (STATE) (7JP CODE)
Who diet on �._ _ _ day of _ i, `'�� �' 200
(PLACE) (ADDRESS)
Name and dd*vss((ofnei+;e-t�riving relative or name of person authorizing c,-rornation:
Relationship to deceaskxa_�.
Name of Funeral Home 1 �
fir,� � l-�j _.. f A✓i F�`��v''�
IMPORTANT
I reprasent that to the test ui my kncwiedye, trig.deceased �►zs no cemaker in his yr her
body. (CIRCLE ONE)
I certify that I have the full paww and Puthmiza6on to grange kr the cremation of the remains and
to dlr act the dispo-,W-n a no cm rartBd;ernalns, that arry peetonal Possessions have either been
removed or may be dasboye.d,and agme tc;pro;e-.1 defend and save harmless Pine Ylew
6rerm3101ium from any and all claims avd dernands for foss or damages which may be made
against them by reason of or mnno-,Wr.with the cm nation of said rernains as dirMted,whether
suds otaictu or�cls ate or are nvt'rvhcity groundless,Use or fraudulent. .J
. ��.11/�ltc�ll. h�/c.4 7 J�r1L_.S,r✓j(�.S_rI'7y
(SI^ T F RFLA7nVE OR LEGAL ,REP AND ADDRESIz)
is date