Rickels, Charles rrOWN OF QUEEVBUPJ/'-
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorl��i�
Name S (',��Qi(�v �i Case# Z Z�
Date Of Cremation / Z— _ Zcc
Time Cremation Started ;�. 301-�-
Time Cremation Completed
Type of Container 14 12, �s�J'
Remarks
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i
Dec 05 05 11:04P HOSFL.IND S RICKELS 518-454-1780 p.2
12/05/7005 16:11 519-793-3641 SINSLETON/St-LLIVAN PAGE 02
TOM OF QUEENSBURY
PINE VIEW CEMETERY 3 CREMATORIUM
Ounker Road,Ouoenabury,Now York,12804
Photos(518)Cremelor(um 7/5.4477 of no answer Cary 746.4476
AUTHORIZATION TO CREINATE
The undentigeted requests and ftox bm Pine view Crematorium.In Accordance with and suited to tts
Rules and Regulations to Cresmets Via remains of:
(Name) (sox)
(Strest) (City) (Slatir) (Zip)
who died an ,�...�day of
(Plec4) (Address)
Name end address of nearest mb"or name M parson Authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
s
IMPORTANT:
i represent tt l to the best of my Ji4vwledge,the decassed hoe oi(has nolpcomaker in his or net body.
(Cucis 0116)
I certify that I have the full power and auMori abDn to arrange For the cremefMn of the rernelne and to
direct the"pceliloon of the cremated remains, that any personal poeeeeelone have+elther been removed
or may be destroyed,and agree to pnAect,defend and save harmless Pine view Crematonarn from any
and all tdeirta and dernands for loss or damages which may be stave against them by reason of or
connected with the crrernstlan of Bald remains as directed,whether such claims.or demands are or are not
w Ily group .false or fnsuduient.
v
} (Addie")
(Signature of Relative or Legal Rep and Address))
Signed on this daft:_ Q^+• - "a-1 --