Grahame, Jean TOWN OF QUEENSBURY
Pine View Cemetery and Cremntonum
27 Qunker Road, Queensbury, NY. 72804.5902
(518) 745.4476 (518) 745.4477
htrp//www queensbury net
Funeral Director: )�,
Name of Deceased: P Pt H A /X kL
Case Number: .2
Date of Cremation: �- — ZGC Zi
Retort:
Time Cremation Started: �—
Time Cremation Completed:__
Type of Container: �'�1��J `3GbAK;;?
Remarks:
Home of NntitrnI Beauty ... A Cood PInie to Live
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02/16i2005 13:35 518-793-3641 SINGLETON/S0MVAN PAGE 06
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road,Queenabury,New York, 12804
Pt dne(5IS)Crematorium 745-4477 of no answer Cemetery 746-4478
AUTHORIZATION TO CREMATE
The undersigned rogosts and suthorb s Pine Visw Crematorium, In Acoor+dance with and subject to its
Rules and Regulations to Cremate the remains of:
.TEf�tJ IC �,Pr�lill'tr1� ,,, FE/✓1 p l� _
(Name) (Sex)
(Street) ( ) (Stat ( P)
who died on _- /L day of &jkeAffl A y -20gI=
at X-7 G RAWf- i ! ve �/foyc ffr �S, A/y zmg/
(Piacs) (Address)
Name and address o�nearest relative or name of person Authorizing cremation:
pi4��Cr E+►/t AAE iZ_#p? GQ�6i17 L4&s/ ju Az&'&�.�+G /NA rS/
(Name) (Address)
Relationship to the deceased 4%&V
Name of Funeral Home .✓ Al i6✓� s"V V
IMPORTANT:
I represent that to the best of my knowledge,the deceased has MOH�pacemskGr In his or her body_
(Clrcle one)
I certify that I have Ike full power and autt*dzatlon to arrange For the c remsdon 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 agree to protect, defend and save harmless Pine View Crematorium from any
and all claims and pemands for loss or damages which may be made against them by reaecn of or
connected with the ,ematbn of said remains as directed,whether such oaims or demands are or are not
wholly groundless or fraudulent.
eel&.;. 'ev l.-Wa 4:";
(Address)
(Signature of Relative or Lagal Rep.and dress))
Signedon•this date: [6 )_005
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