Dunigan, John TOWN OF QUEENSBURY
Pint View Cemetery and Crernn tort u1n
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745-4476 (518) 745.4477
hicp //w).vNv queensbury net
Funeral Director: (it II C1.
Name of Deceased: Lh omen her
Case Number: I L
Date of Cremation:
Retort: Crgwford
Time Cremation Started:
Time Cremation Completed: �-G
Type of Container: C d L4 V'j
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Remarks:
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08/23/2000 09: 10 518- N I
;TOWN OF QUEENSSURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker litoad, Queensbury, New York 12804
Phone(5181 Crematorium 745-4477 (it no answer)
l Cemelery 745-4476
AUtHORIZATION TO CREMATE
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Tire undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulation to cremate the remains of:
or,49 Al /V
(NAME) —� i (SEX)
I Nil
At/ JV , leeL
(STREET) (c,17 Y) (STATE) (ZIP CODE)
who died on_ /" _day ofat
*1LAtr;E, / (A45RESS)
Narne end address o`nearest living elative or name of person authorizing cremation:
ZMAX
Relationship to deceased — -- --
c !li Ce
Name of Funeral Home --
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IMPORTANT
I represent that to the best of my kn Medge, the deceased has o• n pacemaker in his or her
body. (CIRCLE ONE)
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certify that I have the full power an authorization to arrange fC,r the crernatrcxi of the remains
and to direct the disposition of the crpmTled remains, that any personal possessions have either
been removed or rrav,be destroyed.lar+d agree to protect,defend and save harmless Pint]VIOW
Crematorium from any and all claim and demands for loss or da:rtages which may ae made
against them by reason o`or connected with the cremation of said rernains as directed.whether
suc •(arms or dumiand� are are t wholly groundless,false Or f1audulent.
— (VVITNf SS) (AI40RESS)
A /,.
(SIGNATURE F R.EI IV : OR LEGAL REP.AND ADDRESS)
Signed on this
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