Eggleston, Elizabeth rr0q4N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �✓l, ��
Name 1 YLA b-2�--} Z6-,L(' , Q C a s e #
Date of Cremation L — ? `� 2G� �[-
Time Cremation Started Q 'c / A-
Time Cremation Completed r)
Type of Container CAA,72,,� Z0417,,i
Remarks :
1 � 0
2� 35 �,
TOWN OF OUEE14SUUIIY '
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuiy. New Yuik 12UU4
Phone l810) CFemploduoil 745-4477 (il nu answer)
Cemeteiy 745-4,17U
AUTI•IORIZ-A'I ION '1 U UREMA I E
'fhe undersigned requests and aulhurizes Pliie Viuw Giumalummi. in accuidance with and subject
to its Rules and Regulations to ciemale the iemains of:
1,2
(STREET) (CITY) (S IWI E),- (ZIP CODE)
who died on day ul 200 f
ate -r-ra
(PLA ) (ADDRESS)
Name and address of nearest living relative or name of person autlloriziny cremation:
P"� ILI - C"Lz=— -1,
Relationship to deceased
Name of Funeral Home r
I
IMPORTANT
I represent that to the best of my knowledge, the deceased has 1a 110 acemaker In his or her
body. (CIRCLE ONE)
1 certify that I have the full power and authorizalloll to arrallye for the cremation of the remains and
to direct the disposition of the cremated remains, 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 remains as directed,whether
such claims or demand re or are,not wholly groundless, false or fraudulent.
zoo i
( ESS)
(MISIATUR&OF RELATI OR LEGAL REP. AND ADDRESS)
Signed on this dale: is
I
I
I
i
SULLIVAN-MINAHAN &POTTER FUNERAL HONZ ;�
407 Bay Road
Queensbury,NY 12804
(518)792-2067
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation: de f/7 // .G �0�,•�.Go �,/
(Scheduled.Date) (Location)
Manner of Disposition of Cremated. Remains:
Burial at ( �„/� �_ ;,—^f"�„� ❑ Return to Family
❑ Entombment at ❑ Other (specify):
I hereby designate the Disposition of Cremated. Re sand acknowledge receipt of a copy of
tins form.
ignatur
(Printed.Name) (Relationship to Deceased)
(Address)
(Telephone Numher)
"Cremated. Remains which shall not have been claimed. within 120 days from the date of
cremation may be disposed of by this firm by placeme t in a columbarium."
Printed Name of Funeral Director Sign-
o uneral 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 Making Disposition Signature Date
#9 WHITE:Funeral Home Copy YELLOW Family Copy PINK:Crematory Copy CUSINTEN Rev.4/96