Rowland, Diane TOWN OF Q UEENS B UR Y
Pine View Cemetery and Crentatorium
21 Quaker Road, Queenshurt, NY. 72804.5902
(518) 74 5-44 76 (518) 745.4477
htrP://w\vnv.queensbury.net
Funeral Director: J\A
Name of Deceased: (gO CJ k 4 N 3
Case Number: 0 0 0 1 11(
Date of Cremation: 10 - Z Gro Ce
Retort:
Time Cremation Started: 0 A.-V
Time Cremation Completed:
Type of Container: � D►�\ .v,+ T) .p
Remarks:
� 0.A5t7- �o 11 3� r��,
" Home of NatitrnI Benuty ... A Good Plnre to Live "
Town of Queensbury
Pine View Cemetery and Cfematorlum
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office.-(518)745•4476, Crematorium:(518)745-4477
Authorization to Cremate
The urdasigned requests and a udwrizes Pine View Cmmator m.in accordance with and subject to its Rules and Regulations to
c remale the room"of
( ) (CkY) (State) (Zip Code) F
who died on SCE day of J �,y a
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at L`vr�S / i� LL S J �,��� LL
(Pbm) ( )
Name and address of nearest Mv reladae or ne me of pawn au tnorW%aemadm
/L,AJ8-L43 �•� ,.� 3 3 3 S()A; 2 ,s� �e b/ #.5—
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RoMiornsNp to do deommeed�' c%len /"�-Yl-
Name of Funeral Horne / /. +►��K IF.AJ �� h
IMPORTANT: ---�
t repraserd that 10 dta best of nW Ivrcwledge,the deceased Mw)o(jnoddIxIlmworwWo0wbWmyWwvWd
device in his or her body. (CUde One)
I cw*drat I have ful power and a dxNtm m to arrange for the cmnadon of the remains and to direct the disposition of the
cr wditd remains,drat any ponxx i possessions trove etdrer been removed or may be doWoyed.and agree to Wbled, IF In 1 and
save hwrrdem Pure Vlew Crenm*xkrm from any and aN damns and datrnands tar loss or dennagee which maybe made apainnt deem
by meson of or wldh the crenreton of said remairre as dhwfed,whether such dolma or demands are or are trot yAm*
gtburdless.talee /
tom)
( and Address d RaiWme or n erttetMe) _
Signed an this dab
Dtposkm of Gen eed Rennaitne
I hereby drect Pine View Ownftrk m to dtspoes of the crwWod harems as follows:
mom to
1
Odrer arrangements-Plow vow. 1 . w, G L ,L x- U .
if pAveftmoon of amnaled rerneins is requested.dvxk here
Revision:Jammy 1.20M