Avery, Katherine 70%N OF QUEEVBU-f�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorA�6 13 /�. .p.,\ )qC)
Name 01'd rL. ) IV Y� V,CFY Case#
Date Of Cremation 21-- 2CX:9'7'
Time Cremation Started
Time Cremation Completed
Type of Container cA zzdt c)i4(z-r-)
Remarks
&t-ZA w'�-CAZ'd
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Oct 18 2005 14: 41 HP LASERJET FAX 2718810 P. 1
OCT-19-2803 02¢33 AM P.01
'rown of Quoensbury
Pine View Cemetery and CreMgtorium
21 Quaker Road,Oueensbury, New York, 12804
Cemetery Office: 518.745-4476,Crcmatoriufn:518-745.4477
Authorization to Cremato
The uitdanaigrwd roVwom and auft tees Pine View Crematorium,in Wordence Mth and sub;**to Its Rules and R@Wlotione to
araehalt the a Dins at:
r
a�f1
� � (S
/?eat Alf s v1ri',
(6treet / (City) //(Stale) { Code)
who died an fn dayof a'JCTOb�,� Zp
at
l000l (Adkboss)
Name and address of nearest living relative or name of h?Rperson eutthorttinp aeemalion;
-naS P �n ,noA"InhA ,�/
ReiauonshtP to the deoaasod� `f a ri/
Nance of frunerei Horn* /7P. e2P &44 44;h
IMPORTANT: r
I represent that to Iho boil Of my kwwleoga.Ina done {rdps (has no)plammoker,clef W iietpr or any 0111W belby Operated
devkha In his or her body. (0tele orw)
>E
I ott*thsl I have lull Power end sutnoef otien to anpn4r for the ciemetion Of the ranerns end to direct re dlspp him of 9w
aemftgd raMW.Met any pOWMI posefssions nave either been removed or may be dostroyed,end fares to Aroteck defend end
seve htlrmlees Pine View Cromatorhrnt from any end as dare and ownends for lon or damages who may be reed*Donal umm
by nelson Of or Wmeclbd with the crernotion of sold rerrtains as directed,whether such aelrns or demands era or are not.wholy
p Ise or audulont,
i naa) � (Address)
f1Y SS S3 , �e D, N/! pod/
(S oture Off/Wdrove of Relative or Legal Rewosentallva)
0 Signed onthbdale;��_,��r
+w
mspowitonor Cremated Romaint
I hereby dired Pine Vlow Gemetorlum to dispose of the ctomated rernains ss follows;
Mail to _
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Other etrangements•Please epodiy:
It putvertretion er OV"11e0 r*moins Is requested.ChGCk rare
Rav;sian;July 7,2W4