Russell, Donald rl-0 WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name T0hI 1N ID Case
Date of Cremation (�,� l� � 76c) (�
Time Cremation Started
Time Cremation Completed �.-
Type of Container
Remarks :
�1Z N-10 ra l�CJ 2`T Gam �pe,
6To
TOWN U1= QUL=ENSUURY
MINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New Yutk 12W4
Phone t610) Crerr�alurium 7,15-•1477 (it nu answer)
Cemelery 745-4470
AU1'I-IOI1I7-A'I ION I U C;I tEMA I E
The undersigned requests and authurizes I-Ihre View Giemulunum. in accurdance with and subject
to its Rules and Regulations to cremate the remains ul:
(NAME) (SEX)
(STREET) (CI•IY) (S I Al L- (ZIP CODE)
who died on day of 20 e7q
at
(PLACE) (AUDRESS)
Name and address of nearest living relative or name of persun authorizing cremation:
Relationship to deceased
Name of Funeral Home
-- 1 94/—z"X
IMPORTANT
I represent that to the best of my knowledge, the deceased has or 1a I►v celnaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to airallye for 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 creniatloit of said remains as directed,whether
s cl Ims or dam ds are or are not wholly groundless, false or fraudulent.
(WI N SS) (ADDR SS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: •611
a
SINGLETON-HEALY FUNERAL HOME
407 Bay Road
Queensbury,NY 12804
(518)793-4459
"Customer's Designation of Intentions"
Name of Deceased.:
Cremation:
(Scheduled Date)
Manner of Disposition of Cremated Remains:
Burial at y ❑ Return to Family
❑ Entombment at ❑ Other specify):
I hereby designate the Disposition of Cremated.Remains and acknowledge receipt of a Copy of
this form.
(,Signature)
(Printed Name) (Relationship to Deceased)
jAddressj
(Telephone Number)
"Cremated Remains which shall not have been claimed within 120 days from the date of
cremation may be disposed of by this firm by placements in a columbarium."
i'�natur
Printed Name of I unera Director r 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 Person Making Disposition
Signature Date
CUSINTEN Rev.4/96
#9 WHITE:Funeral Home Copy
YELLOW:Family Copy PINK:Crematory Copy