Picheo, Mary , 'rncK C OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
l Funeral Director j /V�, P
Name r/ ' iL jAe'o Case # Z[)
Date of Cremation jf - 3 p zoz> `t
Time Cremation Started YI 3 d k---tom
Time Cremation Completed ,
T y p e o f C o n t a i n e r (ice c'•4 �t7r:;,vi„4} i✓� ���} ,ill i/j,; 11 9 rj'
Remarks :
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PINE VIEW CEMETERY _
CREMATORIUM
Quaker Road. Queeiisbuiy, New Yoik 1213U4
Phone (510) CreirialoHum 7,15--1477 (il nu answer)
Ceinetery 745-4476
AU'11-10121ZA'rION 'I U t:IlEMA l E ,
The undersigned requests and authorizes fine View Ciematutium. in accuidance with and subject
to its Rules and Regulations to.ci emale.the i emains ul.
(NAM (SEX)
co 3u- 1 Z�
(STR ET) (CITY) (S fA i E) (ZIP CODE)
who died on r day ur Zp v
4
at &!�� J �S I�UcJ
(PLACE) (ADDRESS
Name and address of nearest living relative or name of person authorizirly cremation:
Relationship to deceased Y1rl�
Ill
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has Ilo p cernaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for lire 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.
ESS � ( D D rW,\SS)
(SIGNATURLvOF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: •�����/