Tremaine, Rita TOTS OF QUEE9 5B l_ -.y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director ^ iC�14XC-\�
Case#
=a ; e Of Cremation
T =tee Cremation Started 1 12-AA
_ 7e Cremation Completed s
,. e of C o n t a i n e r an,.1 � ��,D y (>i44, c�� �( C)
�.Tsrks
TONN OF QUBEItSHURY '
PrM VINK C IMMY
CRB I&TOltx=
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTWRISATION TO CRXNA=
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
i a- T ✓Lu-1761"JL- Fr ly� -e
(Name) ( ex)
(street) (City) t (State) (Zips)
y� ao�
who died on <'(���, ,� _�nU y of Y1 -19—
at G 1-e►1� �c�15 , k1t nI-J AL f 06 -I(�l - K' k Sj. �61ein ��S N.� 12kQ(
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
_/Ivy �j(f'b��x� �''1r . J� IA)� Ili�xv, C . (n IP�1S ra il.0 N N - 12
(Name) (Ass)
Relationship to the deceased
1
Name of Funeral Home M tL qY a rl D. -&t�e✓ Fun rcl-,�,
IRPORTANT:
I re resent that to the best of my knowledge, the deceased
as no pacemake 'n his or her body. (Circle One)
I certify that I have the full porter and authorization to arrange
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 demands are or are not wholly
groundless, false or fraudulent.
7We (Address)
(Si 5elative or Legal Rep. and Address)
Signed on this date: �a-� �lOL(