Lupinacci, Angelo 70%N of QUEEVBUJ�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director y V." `Z
A
Name A i-k:wCj-0 1--U v >4 Case# y'l Z Z
Date Of Cremation Z _ L4- °--
Time Cremation Started
Time Cremation Completed"'
Type of Container C:�i4,�Zr? 4�U`�-i�� A4"
Remarks
i
TOE
9ZI
OF
PINS VIEN 'l
CRBKATORItTli
Quaker Road, Queensbury, Nov York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AiIOSIXATION TO CRMMM
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
L. T-z .
(N e) (sex)
2
(Street) 0 (city) tate) (Zip Code)
who died on Z day of L-2Z&--V ag Ai9 e S
at D O. h - d-
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
1 (1 GG 2 O S1-Y, a
Address) J
(Name) (
Relationship to the deceased �! -
Name of Funeral Home
ry
rinDo im:
e resent 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 cremation of the remains and to direct the disposition of
the cremated remains, that any personal Possessions have either
been removed or may be destroyed, and agree to protect, defend and j
save harmless Pine vieev Crematorium from any and all claims and
demands for loss or damages which maY be made against them by
reason of or whether ected with the suchclaims or demands Dn of said are or are not remains
direct ho11Y
directed,,
groundless, false or fraudulent.
( ess) ---T(Address)
(Signature Re ative or L al Rep. and Address)
Signed on this date: �r - �►✓ `�G'`�y