Mannis, Frank TOWN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J /V)" t "
Name IqRh IYIAfyn1 % 7 Case #
Date of Cremation, — 2 Z�Gy-
Time Cremation Started
Time Cremation Completed
Type of Container c,,A-\;Ld 13d.-r1ld 'odod
Remarks :
TOWN 01: OUEENSUURY
PINE VIEW CEMETERY -
CREMATORIUM
Quaker Road. Queensbuiy, New York 1211U4
Phone t510) CreigatuHum 745-4477 (if no answer)
Cemetery 745-4470
AU'I HORIZAI lON '10 CRUMA I!_
The undersigned requests and authorizes fine View t;iemaluinnn. in accuidance with and subject
to its Rules and Regulations to cremate,the iemaiiis ul:
(NAME) (SLX)
I q- 7 ? �L-27�
(STREET) (GI•I-Y) ( I A i t (ZIP CODE)
who died on day of 20��
(PLACE) )ADDRESS)
Name and address of nearest living relative or name of person authorizing crern lion:
&A Lu-f� 1127
i1PZ
Relationship to deceased
Name of Funeral Home x:L
IMPORTANT
I represent that to the best of my knowledge, the deceased has o 11as 11 pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrallye for (lie 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 cteniatioll of said remains as directed,whether
such claims or de dss are or are not wholly groundless, false or fraudulent.
(YAIFNESS (ADDRESS
(SIGN URE OF R TIVE OR Le�t REP. AND ADDRESS)
Signed on this date: 0/-1ez-e