Sapunarich, Madeline t
L O rTI/N OF QUEEN O l.,l-P,.y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
^A Funeral Director
s i-P y'sj 14��Ci k, Case#
`a- e CC Cremation
T :T:e Cremation Started
' _Te Cremation Completed Q P l
oe of Container �� '0P4\\ Al I� �
;_—.arks
-All
�4 PM
� A
i
TOWN OF OUL=E14SUUIIY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queeiisbuiy, New Yuik 12BU4
Phone (510) Crerriatodum 7,15-4477 (it no answer)
Cemeleiy 7,15-4,170
AU1'I-IOR1ZATION '1 O CREMA l E
The undersigned requests and authorizes Dine View Glenwtunun'. in accuidance with and subject
to its Rules and Regulations to cremate_the remains ul:
(NAME) (SEX)
K,
oJe S Wa JLYI�(1y1�
(STREET) (CI-IY) (S I"A I E) (ZIP CODE)
who died on b day uI � Y�r3>°�
at G �.�
(PLACE) (ADDRESS)
Name and address of nearest Irvin relative or name of person authorizing cremation:
h�mct S J A�r t c
Relationship to deceased ZI,IS
Name of Funeral Home
i
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power 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.
(ADDRESS)
(SIGNA R F RELATIVE 7 tEGAL REP. AND ADDRESS)
Signed on this date: J Z a 7