Sneller, Tami ' TOWN OF Q UEENS B UR Y
Pine Virtu Cemetery and Cremn►oriiini
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //w%v\v queensbury net
Funeral Director:
Name of Deceased: TA t 5 F
Case Number:
Date of Cremation: EC)G 5/
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container:
Remarks:
vi
Hone of NntitrnI Ben itty ... A Good Plnie to Live
JAN-05-05 WED 02:30 PM CARLETON FUNERAL HOME NF 187461689 PAGE 3
TOWN OF QUE.ENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The;Ulu grargiied requests and authorizes Pine View Crematorium, in accordance with
ar�d:st116JP" t' to its Rules and Regulations to cremate the remains of:
`T1.`. SraQiler
�,.. Mcx
fist) (City) (State) (Zip Code)
r{ o.die.d On .l i _. _....... day of CC' _._ ... .
e Tj
(Address),
Na�4:a6d"address of nearest living relative or name of person authorizing cremations:
W-, s t ?d•.,. .�7 1L__•_.,,.._P_�0 Box 154,__]3S 4ver Creek, OR 97004
?Game) (Address)
Rcief'iorsb)p to the deceased sister _ __.. _,.--...._-_.._..,,.._• ._.._•�,-._
Name.&if-bneral Home
1 1,eprese t that to the best of my knowledge, the deceased has or,"' has no �
lel+ce r �056r":in his or her body. (Circle One)
I derffy'tkat.l have the full power and authorization to arrange for the cremation
of 1hd`r6:6*.ns and to direct the disposition of the cremated remains, that any
vmrs'ona .possessions have either been removed or may be destroyed, and agree
t0,,liroxe,6,1,.-defend and save harmless Pine View Crematorium from any and all
cla,Ims atiktdemands for loss or damages which may be made against them
by rp;`sqn of or connected with the cremation of said remains as directed,
wh0her° Jbh claims or demands are not wholly groundless, false or fraudulent.
' S
Af, Ilk
Pitness) (Address)
=--1rA � Cr-eek� ''
. and Address
:(signat004
ure of Relative or Legal Rep.P )
�iyr3�z9..'acari this date: