Szecsy, Elsie a
Funeral Director: —)R
Name of Deceased: s y C--
Case Number:
Date of Cremation:
Retort: _.'VQ"A LO rt—l_1c-)
Time Cremation Started:
Time Cremation Completed:
Type of Container: 1 A (0 M1 S
Remarks:> I/la—t� /Ire� ' y�
26
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06/20/2005 15:32 8458389251 ALEK P 'SZECSV FAUL bl
�,. 06/20/2005 13:44 518-792-1287 PEGAN&DD4NY #1345 Zk PAGE 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road,queensbury,New York, 12804
Phone(516)Cremetorlum 7404477 of no answer Cemetery 746-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Cremate the remains of.
E z 5 ecsda
(Name) .-7-- (Seat)
IV Y
(street) (a'°te) (zip) .
who died an / 9 day of Inc 20 �s
at .
{per) (Address)
Name and address of nearest relative or name of person Auftrizing cremation:
(Name) (Address)
)s�z rn sZt< - -
Name of Funeral Home --- ^-
IMPORTANT,
I repmsent that to the test of my knowledge,the dd"ned has has�rfoammaker in his or her body.
(Circle One)
I 00ty tfat I have the full power and authorization to arrange For the cremation of the remains and to
lrt?`ct the disposition of the cremated remains,that any perSonsl posalealSWS nave ermer town rvrrivy�
d
d I may be destroyed, and agree to protect, defend and save hatrmiGgs Pine View Crematorium fmm any
end all clalme and demands fqr k�llil Of damases whk may be made apai�ist tF�em try reason of or
conned with the cremation of said remains as directed,whether such clan Mm r demands are or are not
whol groundless,false or fraudulent.
Uilddress)
(Signature of Kelavve qr legal ROP.and Address))
Signed on thls dats:'