Fitzgerald, Carol TOWN OF QUEENSB URY
Ptne Virtu Cemetery nod Crentntortttnt
21 Qtrnkrr Road, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http //w%vNv queensbury net
Funeral Director: / " `- G YA
Name of Deceased: YL Cs.- i2 i'N
Case Number: ( 1
Date of Cremation: 1 0'�- �5 ' 20o 5
Retort: '
Time Cremation Started:
Time Cremation Completed:
Type of Container: Lub)-\ZCl
Remarks:
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Home of Nnrttrnl Beauty ... A Good Plnie to LiVe
TOE OF QUZXNBBURt t
PINS VIRK CENS"MMI
CRE1lWORIDM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AtORISATIOx TO CRRMATF'
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
T �- -
{ ame) (Sex)
3 S Qe' 7 /L -
(Street) (City (State) (Zip Code)
who died on 22. LS T day of �� -+9-- 2
at i F P 'i k7 z
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
AH,J
(Name) ( ss)
Relationship to the deceased 9 3 nA'o
Name of Funeral Home !U �v� - 6- r� ►3
IMPORTAR'T:
I re;7��
o the best of my knowledge, the deceased has or
hasn his or her body. (Circle One)
I certify that I have the full poorer 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- agree to protect, defend and
save harmless Pine view Crematorium from any and all 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 claims or demands are or are not wholly
groundless, false r f udulent.
tg
W tness) J (Address)
U'J kt".Y, ,
MgntAure Relative or Legal Rep. and Address)
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Signed on this date: ��,_,