Hoy, Lois TOWN OF QUEENSBURY
Pine View Cemetery nud Cremntorium
21 Qunker Rond, Queensbury, NY. 12804.5902
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(518) 745-4476 (518) 745.4477
http://wNvNv.quccnsbury.net
Funeral Director:
Name of Deceased: �n,L�) 1, S �K1 YI
Case Number:
Date of Cremation:
Retort: C B)4)P)
Time Cremation Started: 1
Time Cremation Completed: --3c " \,
Type of Container: � ��Z�
Remarks:
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Home of Nnti+ rnl Beauty ... A Gooii Plnce to Live "
05/04/2005 16:18 7610044 MANARD BAKER FUNERAL PAGE 03
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Pin Mall
Alan=
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AMINt¢.
5,
pR2IMON To Cp=
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains Of:
LoI
(Name) o `)
.- �r^�. Ur]Sa.J � S -
(Street) ty) 8 a s ( p e)
who died on _ -day of
(P co) ess)
ITame and address of nearest living relative or name of person
authorizing cremation:
o.0 . C. G; I-XIvr
( e) (Address) �Uu►16TT, 6�s, oiory
Relationship to the deceased 'a'MLL
Name of Funeral Home �.
naroa�r�►rr:
I 1.7
resent that to the best my knowledge,, the deceas ha or
s no pec in his or her body. (Circle'. One)
I certify that I have the full power and authorization toil angs
for the cremation of the semaina and to direct the dispo
the cremated reslaias, that any personal possessions have either
been reeaved or may be destroyf and agree to pMtect• defend and
save harmless Pine View Cramato—M fio1,t any a all cla3as and
demands for loss or damages which may be mad&- �Lgainst them by
as
reatson of or connected eceh claimw for demands he °are or Nwe notw wholly
directed, whether
ground s, false r fr dulen .
ess
din 1) , 2 d 0
(51 urnff RIlativw or Lea Rep. an ess)
Signed on this date:
S�