Francett, John rr0 WN OF QUEEVBUJ�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name jQa l )-RIAL) <.C-t-t Case# � (�
Date Of Cremation Z
Time Cremation Started 3 y3w ✓Lk
v"
Time Cremation Completed (� d �'� A Nl.
Type of Container Gt4a)0,0,4M, 41AI Yk ,. r) 3
Remarks
t�5 �
` 96
Town of Queensbury
Pine View Cemetery and Cr+emakwium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745.4476,Crematorium:(518)745-4477
Authorization to Cremate
The wxkmipned requests and aulhorims Pine view CrWetorium.In aowrdwm wkh and subject to Its Rules and Regulations to
aemsts the(snobs of _
n/K^j c&I-f- bOL e
cJ I i2�19'1 (_ 4 /
(attest) (cry) ( ) (Ape)
who died on day of...- 20
at ccc�'j :-M
(Plew) (Address)
NeowividauressofneervoWftieWwornen of petwm .
Rlay!� c.
(Nameri
(Address)
Relelionship to#ie&wessed GJ _
New of Funeral Home d 1 ( / U^j L
IMPORTANT.
l rdpresen t that to the best of my Imowledge.the deoeasad(has lhas no) etkxlkslar or any add battery operated
device in his or her body. (Grote One)
1 cw*that 1 too IA power and&SWIZatioa to 8E110 for the t meson of the ieWwk s and to dared the disposi im of the
aerrrelod rereains,that any peraorial poaaeestorts have eldar been ramowad or may be dsssayact and aproe to pttflsct,defend Wad
eewe hstrtbss Plus 1Aew pantatotluat iiom Wty Wad allcMw sad desnattdefor toes or dswasswlhidr may be msda egad 0 them
by eeaaon afar ' wih the Gaaration of said nm wine as dlnicied.ododwr such tleiaer Or demstds are or are at who*
i7
and Address of F'WiW ee or L"W Represents")
Sipped on this date:
Didposikon of Cremated fW ains
I hereby diced Pine view Cmn*tud m to dispose Of the c mmff ed rerrreirrs es f ftm
Mail to
tldrer arrangemaeft-Please spedhr.
ff pukwizow of cremated retnakrs is requested,shectc two
PAwlsion:Jammy 1,2WG