Manzo, Judith rro74N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1 Funeral Director s,I��CJ 1�
Name oDi_i n ,A.w rL0 Case#
Date Of Cremation 2 `f - Zco
Time Cremation Started c� P V%
Time Cremation Completed
Type of Container �►� � ?�� i`1�� j ��
Remarks
Y
3 -12
1
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TONN or
• PINS VrZK CBNBTSNY
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CRUNAM
The undersigned requests and authorizes Pine View Crematorium in
accordance with and s ject to its Rules and Regulations to cremate
the remains of: tAOl11 La�
Name) r V (sex)
(Street) (City) (state) (Zip Code)
who died on dZ day of
at I .A R Rd- ('jn,,'n -�Z
( ace) ( e s)
Name and ess of nearest living relative or name of person
authoriz' ion:
(Nam ( ess)
Relationship to the deceased
Name of Funeral Home
ImPORTAIiT: .
I represent that to the best of my knowledge, the deceased has or
has n in his or her body. (Circle One)
I certify that I have the full power mad authorization to arrange
for the c vnetion of the remains and to direct the disposition of
the cremated remains, that any personal possessions have either
been L removed or may be destroyed, and agree to PrOtAmt• defend and
save ha=mless Pine view Crematoriun from any and all claims and
demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witnes ( ess)
(signature of-Relative or Legal Rep. andAddress)
Signed on this date:W 1&-t7. � ZV d