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Donovan, Lena
Funeral Director: �► �'�C) " Name of Deceased: L I% W P � G Case Number: 2 Date of Cremation: 2C�JSr r- Retort: Time Cremation Started: -11t4 Time Cremation Completed: Type of Container: L �(>?�'r4'� Remarks: I pill A Z 4 AN i i 06/08/2005 07:32 5185854475 WILCOX REGAN j PAGE 01 M. TOWN OF QUEENSBURY ? PINE VIEW CEMETERY CREMATORIUM Quaker Road, Queensbury. New York 12004 I xirte(510)Crematorium 7454477(if no answer) Cemetery 74544.76 t AUTHORIZATION TO CREMATE Tile undersigned requests ark w0wizes Pine View Crematorium, in accordanco wi(Ii and subject to its Rules and Regulations li-cremate Use r9makts of. jigna_Ruth Donovan Female (SEX) lndi�a,n River Nursing Home, ranville New York 12832 ` (STREP) (CITY) (STATE) (ZIP CODE) who died on_ 4 th day of June 20 05 at~ Indiap River Nursing Home, Granville, New York 12832 (PLACC) (ADDRESS) Navin avid address or nearest ii V relative or name of person auUwrizklg cremalion. Aatri nk unnayan- 67 Canf'gid oad Ticonderoga, New York 12883 Relationship to deceased__ Son Name of Funeral Home__ wi laox & Regan Funeral Home IMPORTANT I represent(flat to 00 best of my blowledge,the deceased IM or to o acemaker in his or her Wdy. (CIRCLE ONE) I certiry Utai I have Ute full power end eWMIzallon to arrange for the cremalim of Ute r©mairts and to dired V*dlsPo$WM of the WmWed remabu,that any personal possessions have eitlier been re ed or may be destroyed;and agree to prate4 defend and save Ilarmiess pine View PmMtOdUm Iron any and IN claims and demands for loss or damages whicil may be made agaMst Diem by reason of Or wnrOded with Die cnernaUon of said remains as direded,rrlre(Iter such claims or demands ere or are not Wwly groundless.raise or fraudulenL ESS) (ADDRESS) c (SIGNATURE OF RELATIVE OR LEGAL REI'.AND ADDRESS) Signed on Uric date:. W/' Y' D