Voll, Marie TOWN OF Q UEENS B UR Y
Pine View Cemetery nnrl Crernnlormin
21 Qunker Rond, Qneenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
h(rp nw\/\v queensbury net
Funeral Director:
Name of Deceased: r \ N\/*7v %
Case Number:
Date of Cremation:
Retort:
Time Cremation started:
Time Cremation Completed:
d
Type of Container: MA(0.V
2 r7'!•�
Remarks:
n / '\' nf ;trnl Beni, I A C0od PInie I L � �
3 R�
TOW or Q�vst�r�wo'et
PIM VZ= CSC
% T-& A!
QuatkO r Road,, Quemsburyp Her York 12.804
Phone (519) CrMatorium 745-4477 or if no ansiter
Com tery 745-4475
The undexaig ed requests and authorises pine vier Crematorium, in
accordance with and subject to its Rules and Ragulations to cremate
the remains of
(Nasty r ) ----.-
( t) (CItyY J,( toe) (SIP Code)
rho died on � _ � r . day of
at
(F ace) - (Andres*)
Wass, and address of nearest living relative or name of person
authorizing cremation:
V, s 39' Lon U.,c&j a-. --
( ( I) QU&tjSkA ryjIV�(.
Relationship to the deceased Af SllorvJ _-_
Nam of Funeral Home �1�a rG �• 1���� �-- �
I re=ft&ft= that to the best of my hnovledge F the deceased" has or
has 43jo acem in his or her body. (Circle One)
I certify that f have the full power mind authorization to arrange
for the creiation of the rumins and to direct the ition of
tche crumated r�;ns, that any parsaa�eetl poaaa�rrs halve either
boon. removed or may be dentro !- r and awee to prottaectr d tend-mid
save harmless Pine VIOW Qreamatorivt fx m any and all claim and
demands for loss or daseages rhich may be made against them by
reason of or connect+rd Frith the crsmtion of said rsmMins As
directed, vharther Inch clat M or demands are or are not wholly
groundless, false or fraudulent.
• g ,
(w tees ( ess)
(-Signature o at ve or Legal Red►. an esr)
Signed on this date:��5