Dube, Shirley TORN OF QUEEVBUJ y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director T3 4 X
Name rLLLtf ,M )jJ Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container IIAIZ,y c'Jy G am - M ✓.a- ►'1-4 - � � 2-0
Remarks
Inavelel
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Town of Queensbttry
pine View Cemeb"and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)7454476,Crematorium:(518)7454477
Authabmtion to Cremate
The WXW90W reque m and authorizes Me View C enwArlum.in a=rdance with and subject to ilss Rules and Reguldions to
cremate the
reffw!�
su q H P1.)0 124,3 A/I (5"
(Street) (CRY) (State) (ZIP )
who died _ � L day ofat
Mew) ' )
address of Nftrabdwortol of povw autlrorizhrg cremadw
m b N" Vou G'
(I,�1e) (Address)
Reiadwship to the deoessed
Name of Furrenai home
IMPORTANT:
I Imp s oerrt tot to ure best of my knowledge.the deosesed(has)or(has no)peoegl w.delbWato or any adw bef"openad
devioe In his or her body. (Chas One)
I aeay a"I have WR power and augmxtmdm to arrange for the oramne w of ge renreln at the clap and to throat lapo Wi of the
ied creme r ar Okla that arty persona,poasaeslorrs have eNo been ramarod army be demgoys&end apes to POW defend and
savehumlmft*VnrCrenrswioriuetiromanyorbaliddm Add, i 'P lwtoesordwopeswWdrmaybemadeapeltrsttlram
by reason afaroorrrecleti wags own" of said rarseirs ss drawled.Anger such deans or dernermis are or an ra whobll
I -
(Address)
of or Low
Soo on dris doW
oiepoabion of creed Remehrs
I hereby dhect Pure View QrerrroA m to diapose of the c mnmtled ream**as 1000 :
Mai to
o6w emerds-Please specify.
#puWermstion of crerrarled Mr*kms Is requested.check two
Revision:Ja miery 1.2WO