Webb, Wesley OF OUEEN'7 5B UPJ/'0
PINE VIEW CEMETER'r AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YOR.K 12804
(518) 745-4476 (518) 745.4477
Funeral Director
Case#
Cremation
Cremation Started
e Cremation Completed
. 1e of Container rj �0 nt
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01/27/2005 15:59 5185854475 WILCOX REGAN PAGE 01
TOWN OF OUEENSOURY .
PINT=VIEW CCMETERY J
a
CREMATORIUM
Quaker RvaO, Oueenebury. New Vaik 12e04
Plana(518)Gr0rmtorlum 145-4477(il nv answer)
Cerr►elery 745.4476
ALIT►KIRIZATIUN TO CREMATE
11re w Wersow requesis end aulholzet Pine View Crematorium.In accordance will and subject
to hs Rules and RegulaWns to cremuls the rernaUr of:
We 1 --..-----
( ) (SEX)
cse Y 12823
( (c1 (ST I:-) ZIP CODE)
who dw on 25th day vl ._.Tat►uary 20--as.-
q 2883
(PLACE) t SS)
None and oddreec of nearest Iwtnq aeWtve or nama*(Wm aouw4kV cremmllm.
Ta"y Beeror. 1080 Eddy St, ,, Apr 2o! . c„n p• an j am Q& Q4109
RsUumsNp10daoegssd Daughter
Name of Funmel Nome e S t .
Ticonderoga, New York 12883
IMPORTANT
I n"m"that to the bed of my knvpledpe,the deceased he cemrker in his or bor
boy, (CIRCLE ONE)
I ON*li»t 1 have the fuN power and rl lho llltbn to erraflpe for the cremation o1 Ole remains and
to dhect go dtyr osit)orI*Igo mated renulns,that any PetWonat porisessions have eOmf keen
or may be destmayad;and agree to pmleol►00Qv d"Id We hem t&ss Pkm Vimw
odd kom ml VFWaN datrrrac W4 demands%r toss or daurgM whidr nay be made
'egldrat them by reason of or m7no*d wNtr the aematlon oftt81d►WvWM ai drecled,whether
such d ms or demands Ms or we not wfwlly prowrdlese, lal"or kaudulent.
l (NVITN (App1iE5S)
( TU TIVE OR LE(;AL. - . 0 ADDRESS)
SVned on thla data:._