Dubec, Helen c
T0J+N OF QUEEVBU-9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '-S-t
,Name )b Case# �1 S t
Date Of Cremation 1 U -- �3 iTime Cremation Started ✓(/�
Time Cremation Completed l J ZsV �l
Type of Container
Remarks
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TOWN OF QUEENSBURY
f 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
saand
/Regulations to Cremate the remains of:
W A&-e' FVI' 94�
(Na (Sex)
me
316 Jet&met ,cl .
(Street) (City) (State) (zip)
who died on day of � G�Y 20
at jd,.Zt
(Place) (A ress)
Name and addre s of nearest relativ name of person Authorizing cremation:
4
, (Name) (Address)
Relationship to the deceased
A'Atr-
Name of Funeral Hom
IMPORTANT: '
f represent that to the best of my knowledge, the deceased has or as no cemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the cremation of the remains and to
direct the disposition of the cremated remains, that any personal possessions have either beert 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 gainst them by reason of or
connected with the cremation of said remains as directed, whether such clis or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
(Signature of R61ative or Legal Rep. and Address))
Signed on this date:
as .:ar,-as<�:K�wb�.�. .:rn YS.n .I�wesn-'.r,.e�!�T..nr.�r�u,�'rA•••d�•.r. ...,,Y...wo-»��gYl�'•a .
r.lzlm f Mk Idle �I ask
Age If Vets i an o+ U orces,
92 War u, pp•,
Hospital, Institution yr
aqe Fort-. ,rdward Street Address Fort Hudson Nursing Facility
Natural C,rr :Accident Horri i Ie Suicide deter G «antes Pending
vestigatiw,
.';-,1ier Nam D Title
,1.-I0res t� OG.d "Tv77t GfJwaA k �Z�Z�
--- N
l; rm `_er .. Register Number
Edwiird
l;•ir-ubtAry or Qrematory
CcJc)� �1 ._�5 , t►h y�ety Ch�
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i "I R , ,dlor Held
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• `rl?;rat � 1
(;�>r ,;:cr' Destyrration _ _i
i
alllrr
_. Date [T; -M tery Ail ess
n [_j Disinterment
❑Reinterment
Date ` r�emetixy Address
.-__ ._.. ----- -------- _ __. -- - � .. .___..
r suet'to RegisrrAtkin N rLif;?;..._
�l i p `F ,-ral Home Sull.ivat,-Mir..-Iilsw a• Potter F.-,"
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Rorr.d, Queensburx, New York 12804 i
I t ) ,r ra' Firm Making Dispf)sition or to Whom _
F r . !i;pped. If Other than Above
E
s Permission is 1' b witc-d to dispose of tho humari r v.pins described above L-indicated. 1
/�
Date ' skwr,rf �� — :gir;trar of Vital Statistics
I � �net}nAtrizHt '.. ... ___... p
r ;
j District Nurnber lylar�, ;?off t: 8dward,New Yo
-�- ) -7 r6
r;-fri+fy that the rovr ;ins of tht., identitiect above were distjosed%t w, :f(.rwdwnce ,.7i;."ta.; o rmit on:
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