Sullivan, Helen LO YVN OF QUEEVBU.I�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S; tG�;� � . - �Iry,,�y F. �I
Name H6 , S S;, (I Case # L115
Date cf Cremation
Time Cremation Started 1a-.30
Time Cremation Completed
Type of Container 61 Cr';W-4rd b d r,
Remarks : i
TOWN 01: QUEE14SUUIIY ^
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuiy. New Yolk 120U4
Phone t510) Creinatodunr 7.15-•1477 (if no answer)
Cemetery 740-4476
AUI1-10111ZA-IION 10CREMAlE
The undersigned requests and authorizes Dine View Giumatumml. in accuidance with and subject
to its Rules and Regulations to ciemale,the remains 0:
(NAME) (SEA)
Zc� - Z r2h� Gc�xti L _� 12
(STREET) (CITY) ( 1 A 1 E) (ZIP CODE)
who died on O�� day of �� b 20 U�
at
G .
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
n�-
Relationship to deceased -
Name of Funeral Home t t
IMPORTANT
I represent that to the best of my knowledge, the deceased has Or fas no cernaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to artanye for life 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 demands are or are not wholly groundless, false or fraudulent.
TNESS) r, ADDRESS)
(SIGNATURE F RELATIVE OR AL REP. AND ADDRESS)
Signed on this date: