McPhail, Dorothy rl-o`14N of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director. ���, G;� .� f��,nyl
Name 001 H5t Mc Case # V��3
Date of Cremation i(;— 2� •, G�
Time Cremation Started "I: 3 A _ M
Time Cremation Completed
Type of Container C9rcl
y
Remarks :
Mrl1n 1- S0 A - d - q ,, N 'a �1 •1-�
! . ( 6 A.
(r : 36 H . M .
tp3
10/25/2004 11:46 518-792-1287 REGAN&DENNY #1346 Pt46E 02
}'OWN 01° OUEU-143UUIty
PIN .VIEWCCh1[l'GIiY
8
C14EMA'f0111UM
Quaker Road. Quaensbuly, New York 12UU¢
Phone tG10t Crematullunt 7.1(;..1A77 Ili nu answer)
Ce�ftetery Tnc.%lara
AU14.10 312ATION 10 UI IEMA 1 L
The urtderstWnad requests and authuelLe9 Dille view ill DUCUld0llae Witil itlni SUblaCl
to its Rules and Requlaliotin to Cionialel the iema as ul:
Dop, Ale dog !YO— &J o r / 1E.—*-/�
4(,AAP Q4_Rt%1E .0 f2d L�lAe.d N�
(STREET) (GI'lY? t51'A"f Lj (Z1V CODE;
who died on .—day ur e' er *6,cR- 20 _
at
(PLACE) (A t RUESS)
Name and address or nearest living relative or dame of person autitoriziny cremation:
-,Tef S,6 41 / �� sal./ � �'&&4v IAIT Av/94
Relationship to deceased Dp !gk tj 1a .
Name of Funeral Nome RgF,4rr
IMPORTANT
f represent that to the best of Inn knowiedp, late deceased has utoi4�acetnekar in his or her
body. (CIRCLE ONE)
I certify that I have the full power and sultlar►zation to arrange for Ilia cremation of the rernalne 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 malt
against them by reason of or connected with the cremation of sold remains es dhecled.whether
such claims or demo 13 are or are not wholly groundless, false or irauclu{ens,
{ TS, (AOD ESS)
All
1 is
(SIGNAT E OF RELATIVE OR LEGAL REP, ANO AUURESS)
Signed on this date:,