McKeon, Hugh III TOWN of QUEEM,50U9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.44477
Funeral Director ;4 -�= 1��
-e H O &C't L Mc,Kfit Case
_ _ . e � f Cremation 1 1,k —
" .-s Cremation Started
-e Cremation Completed
:e of Container ('A -'C-� l,�d V:v��U ✓� ✓} 1 �� >
� _-arks
TM OF QUX -un _ 2
PIM 4IMF CRY
Quaker Road, Queensbury, New York 12804
phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
ADIUMTZUXGR To ITS
The undersigned requests and authorizes Pine View Crematorium,. in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
h T. MfICOC It7--
(Nam (SOX)
a(0 "I"UMCA, Sf • - -U) i
(Street) {C ty) (State) (8 p Code)
who died on „�� LI day of rAs104"
at o t .0 t Mpt.Jg P 'i t)
( ace) ( res s)
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) 1
Relationship to the deceased W1 e
Name of Funeral Have�t,lrn a ►--d O 4 e- 45un,t���
n�oRTA�rr:
I re resent tho to the best of my knowledge, the deceased; or
has no pa Maker 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 agr" to Protect, defend and
save harmless Pine View Creaontoritta funs any and all claims and
demands for lose or damages which may be :wade against then by
reason of or connected with the cremation of said resales as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
0
( ess) (Address)
-rn
(SignatWe of Rea ve gal Rep. and ess)
Signed on this date: J �. (>>-�