Richardone, Robert TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crematorium
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
hip//www.queensbury.net
Funeral Director: G LG �-�-� Z�G~� S ►n
Name of Deceased: �`�
Case Number: 1^�
Date of Cremation: )�I 2 ! `Z G 6
Retort: � ICJ Q Ck�A 4/
Time Cremation Started:
Time Cremation Completed:
Type of Container: c�A- y i2—U /K 2�-� H 15 f',�q
Remarks:
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Nov 21 05 11:07a P.1
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Town of Qu"nsbury �O
Pine View Cemetery and Crematorium
21 Qulakw Road,Queensturyr New York, 128CK
Cemetery Offlos: 518-745-4476, Crernatorium:518-745-4477
Authorization to Cne MIS
Yt+e undwswod requests and auhoeam Pine view cramatorlum.In aaoordwm villh and stMsC to 1"Rulm and Regul MA W to
aeme0e Mee remab"of
4S P-16rPASIP-9 Nil, �J�_ od ► rJ. .
(S"at) (mil►) (SO") (Lv coda)
who died an i� dal,d � C�L 213
at
Name and adddea of needeet IWWV delawe or mama of person ou#wFbina c—notion:
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(Name) a+�)
Relatkwohp to the deaesmW rW� � rr
Name ofFumrai Home
IMPORTANT, d ocwwd(ha) �no) -,dollbrlllator or any other betWy apersted
t rripraBeru that to the Dad of my Ip�pwtl4ae,v*
0eviee in his or her body. (Cirde One)
1 aarWy tint 1 hwe w power and sudrottmWon to mange for the aefi-daft d 60 m"Oku end to direct the dispnsldM Of the
crarrtated reanhrs.VW soy Degonet poerraepatodts Rave dater bass reatatrad or may t e desroyad,end apron to pmlact,defend and
save harmless Pine vlttw Cd frteMafun from wy aM all deMM end dwm nb for lobs or dmnsps6 MMich maybe made 8WAW them
by,e,�od,of wklt the or.matlon of saw mmdna as dratted,w a thm Ru chime ar denta+ds era Or"not wholly
adou<d1e� tx 110. 'v/]G.1 J� IU-f
r (Wrnaaa) �Addrar�) j �r 6)
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(Sl mtuFe and Iddraes/d ReloWe or Legal Aepresa UM-)
Signed on INS date ���J � S
DhpooBbn of emnatad Remebw
t heraw direct Pine Vtew craRM40 t im w al9poae of to crawood nxrdWw eS l0�onrs
Mall to
oetar arrsnaemants-Please speciV
it pumpt colon or cremsted rerepins Is rgq%w*tpd,deck hde
Revision,.Italy 7.2W4
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