Quinlan, Thomas TORN OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_A '3 k, C ,
Name / �r"1/4�' � 0 'i��, �^-� Case#
Date Of Cremation Ito
Time Cremation Started 9 "Ll
Time Cremation Completed
Type of Containerc4kyzd &4,2&1
Remarks
E 2 Ca 411-(1
i
Wednesday, Cotober 12 20U'D 1-4.20 AM Nancy 4bU-1/&-1414 � L- P.u-
10/12/2005 '1."4 5187477543 M.B. KILMER PW2E Of,
• TOWN OF QUEENSBURY
PINE.VIEW CEMETFRY
8
CREMATORIUM
Quaker Rvad. Quesn0ury. New York 12804
Phone (518)Crematori;;+-n 745-4477 (if no answer)
Cemetery 745.4476
AUTHORIZATION TO CREMATE
This undersigned reUud5t: anti authoriZ@S Plne View Cee-matorium,in accordance with ano subloct
�q it$ Rules and Regulaaons to cremate the remains of
(NAM I„ (SEX)
5S � a &o_G len s �s GA 3
(5--REET) (UITY) J (STATE) {ZIP C0
who deed on
/ Clay of
If ir
at
'PLACE) (ADDRESS;
Name and address of nearast living relative or name of person allMcrizing cremation:
`L.fr2t:2 � ✓� � �,ar'i"ti -C�.��f.:�_�J. fV}�,�/�f� �` ^ ? tr y�,,�;r;mot f•I'�a`JrD r�v,-, .
ReletionShio to deceased
Nacre of Funvral hon7B_
IMPORTANT
I reoresent that to the best of my knowedge. the deceased WU cr n ro;pacernaker n his or her
bo4y (CIRCLE ONE)
I certify that! have the vii power and 8uthorizatiion to wrarge for the cremation of the remains and
to direct th•e disposition of the cremated remains, that arty personal pcssess(ons nave eitner tsaen
removed or may be destroyed. and agree to protect, aefend and save harmless Pine View
Crematartum from any and ail Claims ana demands for�oss or Damages which may be made
against them by reainn of or connocted with the cremation of Said romaiMS s a d�(sctod,whether
such claims or demands are or are not wholly groundless, false or fraudulent
(SIUNAIURE 5—FWT1'Vr79 LEGAL REP AND ADDRESS!
Signed on this date.,rAD 05 — __