Conte, Robert r irrnrvJ
,- - _ a�v i':Y:' - i•. `'mom.,.,. .1,T't;i';' - .
rrM N OF QUEEN,5BU
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director A/� 13
.a : e F Cremation
' .•-e Cremation Started �( �� S/ ✓��
' :-e Cremation Completed �,
e of Container r, Lo of-A CAS,Y�� MLl'1(�l� ,D 1 �
.-arks
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PIM vim CB�tN'tBAY
��` CR81�fATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AVt8ORTZJWZOo To CRSltA'1'S�
e undersigned requests and authorizes Pine View Crematorium;, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
Name) (Sex)
C/1, Ids rV, W Z
(Street (City) (3 e) (zip Code
who died on of 19
at S J7 l r V V Cj
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing CO,
`
A)tC-k-- l , " �y� cj.vi��ivSviCL.c� , 6la AL X, /' 2 ay
(Name) (Address)
Relationship to the deceased S'y.AJ
Name of Funeral home �'/ . 1) , Be7c.tL,,,- F
IMPORTANT:
I represent that to -beeth.r��yy.
- --knowledge,, the deceased has
h or (Circle One)
,pt ACe rn E✓r/y0 �� ,
I certify that ha and authorization to arrange
for the cremation the r to direct the disposition of
the cremated remains, 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 atl 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 Oxm or demands are or are not wholly
groundless, false or Xent.
((Qj the ) (Address)
(Signature of Relative/-or Legal Rep. an ess)
Signed on this date: f
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