Harrington, Rita z'O74N OF QUEEVBU-I�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director _,P�r Q� /✓ �( 'Y
Name V;r P4 N&;t-oI Case# �2 �j--
Date Of Cremation
Time Cremation Started `�' 3 �� 14
Time Cremation Completed
Type of Container 0`5e)
Remarks t
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12/09/2005 13:34 8027662031 DERBY GREEN PAGE 02
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TOWN OF OMEN39URY ✓! ��
PINE MEW CEMETERY a CREMATORILW
OLOW hoed,tiuowwbuiy, Now York, 1211104
Phw*(510)CramaWum 74O4477 of no a*~CWfoe q 746-4476
AI rKPIZATION TO CREMATE
The wWwg p nd r, *MW and suNrorbws plMe VOW Cnsmabrlum, in AWWdWW&with SM subjttt to fie
RuUNst and Rpulatl: b CMWats the rwnalns of.
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who dled on dsy of_- ec ,,�i�rr 20 C
( ,) (ems) C
Name and addrsst of r w4W olobw or r4wm of psrsor►1lufhorising orsrnetlon:
_. m,r ►1 r, ala`i r1
(Addrum)
ROWWnship to the deoeaMd ��
�i M •■ Yir�
Narno of FurarW Florae +-
IMPORTANT.
i represent that b the Owt of my krwwlodp,tM ds ASW has or has no pacoMaiotr in he or hw body.
(Oka*One)
I Canty that I four the lull power and oWfarWMm b anoW For the aWr4Wn of"►arms and to
dW*a the dlapmoon of Ou or neftd rwr**w. to any person« possessions have either Deep M"Wved
or may bo dostrpyed,and ores to proissl,dsf4- and saw harmim Plro V%w Cmrrab(lurn thorn any
and 40 Cretan and OWWds for loss or dsmpss w IM may bs made opftl than by nasal of or
ooruiact d*0 the ommullon of sMd movers es dinmW,whWw such CIMmo or dsnvnds are or am not
WholY OrQI/f+dlsss/We*or fr&Wukmt,
( Ip Nsare or L4W Rep.and )
Signed on this dart: ��