Kobylarz, Eleanor a
TOWN OF Q UEENS B UR Y
Pine View Cemetery nnrl Creinnlorium
21 Qunker Rond. Queenshury, NY. 72804.5902
(518) 745-4476 (518) 74 5.44 77
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Funeral Director: ZZJ4J , L-A
Name of Deceased: VkT A to0('L 'I-,'.013 Y 1-1'+"-'L
Case Number: 3 cc 3
Date of Cremation: _ l — � 'y —Lea
Retort:
Time Cremation Started: Z l /+-4,A
Time Cremation Completed:
Type of Container: ( -P% i P��-�y� yY�s /��} 1 _ �,
Remarks: j 5
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TOWN OF QUEENSBURY
••°` PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518)Crematorium 745-4477 of no answer Cemetery 745-4476
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:
Eleanor J. Kobylarz Female
(Name) (Sex)
4 Queens Way Queensbury NY 12804
(Street) (City) (State) (zip)
who died on 21 day of September 2005
at 4 Queens Way Queensbury,NY 12804
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
Daniel Kobylarz - Hughes 4 Queens Way Queensbury,NY 12804
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Singleton - Healy
IMPORTANT:
I'represent that to the best of my knowledge, the deceased has or as no pacemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the crematiot .remains and to
direct the disposition of the cremated remains, that any personal possessions have either6een removed
or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
and all claims and demands for loss or damages which may be made against them by reason of Qr
connected with the cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, alse or fraudulent.
Queensbury,NY
( it ess) (Address)
Aj • 4 Queens Way Queensbury,NY 12804
(Si (ature otAelatod or Legal R . and Address))
September 21,2005
Signed on this date:
I