Fillioe, Donald Sr. TOWN OF QUEEM,s B U RY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director
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Cremation
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TOWN OF OUCPsNSQUR�'
PINEVIEW CEMETER
8
CREMATORIUM
Ouaker Road, Queensbury, New Y6* 12804
Plumlo(510)CrerMtotlUrn 745-4471(1(na answer)
Cemetery 745A476
AUTHORIZATION TO CRF'MATE
The undersioned requesls and aulho*vm Ping view Creinato lum, in accordance with and subject
to Its Rules and Regulations to cremle The remains of;
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j�(L &Mns _Ei 1 1 1 nP _Sr Male
(NAME)
(Sex)
i
88 Cummin s Road Putnam S n
(STREEI) (CITY) (STATE) (ZIP CODE)
whp fled on 3 pth -- day of Der�tnb6 ,,�z0_Q�
of Moses-Ludington Hospital, Wicker Street, Ticonderoga,�NY
(PLACE) (ADDRESS)
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and sAiress 91 nearest Irving rate of trl pergoq utho ' cremation: .
io
Retartlonsidp to deceased Pau later
Name of Fun"Hume W1 an f n „__lao► e
IMPORTANT �
,} I represent that to the best of my kwwledge, the deceased �acenwker in Ids or herbWY•,(CIRCLE ONk�
Ilk
I hatre(be 1110 PcF mr and euUXft8jiW to arrange lor the cremation of the remains and
to direct the dlspc>'eitlan of theOMMORtEQUIOWhat si<ny poessloas have either been
r�e !°�ed of may be destroyed,and"to prated.defend save Ita►rmtets pine View
taium from WW and ell dakns and demands for bss orO mages whIch may be made
against them by rea$M of or Wmeded w►Ith the trVil11on of bald remains as directed,wimther
such cb ms or demmWs we rN we rrdl Mxgly gmundtess,fe10 or fmudulent.
X (1MTNESS) (ADDRESS)
Oa
-(Sid NA7URE OF RFAAnVE OR LEGAL REP.AND DRLrSS)
Signed on this dater 6
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