Gill, Ronald Funeral Director:
Name of Deceased: tJ 1�1�� M ��IV
Case Number: f-e L+
Date of Cremation: -7, L
Retort: C tz ti Ltd C11
Time Cremation Started: T) �Vl
Time Cremation Completed:
Type of Container: � M
Remarks:
r �
Ct .�'�
UJ/LJ/LC70:J 1 r.G7 O1�'--070--L f�F3 Omr-wtm PUI17tMkL r'Hl]t r71
Town of Queensbury
Pine View Cemetery
8
Crematodum
Quaker Road, Qwwsbury, New York 12804
phone(518)Crematorium 745-4477(it no answer)
Cemetery 745.4476
AUTHORIZATION TO CREMATE
The ung w aoxi rewettt and authorizes Pine View Crematorium,in a000rdonoe with and subject
to its Rules and Repulations to cremate tt►e remains of:
Nanie learn
CA .ilk / �7
sn.w city stela Zip
who died on �., day of T—L21 - oo
a'�Lf—
Add
Name and addrow of nearest living relative or name of person authorizing cremation
aell
Relatlonahip to deceased
Nome of Fun"Home
IMPORTANT
t mpeaartt that to tFM but of my knmAWae,the dsosaaad ho or has no pommow in tw OF W body(CIRCLE ONE)
I oe*ow I Mom pow and authors: bon to wwpe for ttw ww aow of the reruft end to direct the d oposom
of the arse - nn ow,that any pmww pmSmaiana have e*w bean WWAd or may be destroyed,and spree
tc ptgbe-,chftid and awe horfft"Pint vtaw crematorium from any and aM owm and donwnde for b w a demO s a darn- j
sass whtoh m s+sects ap hM Vwn by osason on or offlneWd v*h the awn@00 d said r nWna m dhadW,Who#M ad,
OW s at dwm nda are or are net wh*QraruuMsu,false or frwditlait.
Witness Addfm
($IGNA u.
RE f RELATIVE OR LEGAL REPRESENTiTIVE)
6WW on this date
I
I
I
I
I
I
i