Harrington, Francis R -
QUEEVBU9K
TOWN OF
PINE VIEW CEMETERY AND CREMATORIUM Y
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director,`
Name 25;4-tV j -O, t4j 1,Jx4 J r1(,+Q? . Case# z/z �P
Date Of Cremation — 10 -72-&J 1,7
Time Cremation Started 10Q,,, �` f
Time Cremation Completed —
Type of Container C,�44LC) _tJ A
Remarks
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Town of Queensbury
Pine View Cemetery and CmakWum
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745.4476,Crematorium:(518)745-4477
Authorization to Cremate
The rprderSWW requests anti authorizes Phre View Cr emet 1um.in accordance wkh and&Mod to its Rules and Reptdatiorrs to
cremate the remains d:
(Nww) -
2 0 oz. % f ��nrL, C ►3 I Z� C`f
( ) ' (Gitf►) '— (State) )
who died on day orat
tom) paddraes)
Name end d nearest Bv1n0 or rrarrte of person aulhorizirg aemetion: �(>> n�J�
Name) (Address)
Rekdonship b the deceased S / (03
Name of ftneral Home / 'Pg7 /L IZ.
IMPORTANT:
i represent that b the beat of UN Ivrowiettpe.the deceased 006)or d rRator or OW Ulm battery operated
device in his or her body. (Ckdde One)
1 CM"ffy that t have fd power and audMtMdan 1D epatlpB for the for►cf the rerrreirrs and b diners the di9pos#iort of the
cromated rernair�s.that any personal poaaeaelorra hme aww beet►mrAved or may be***eyed.arrd tprea b ps�lect.drrierrd and
sable pym y�QernatotMrgl than sty and ad claims and darrtar foes a daarapeavritidr stay be made apdnst them
by-not on of �aI I I'd vft the d acrid nerrrairr Ise wlratNtr such cteias a dawrstda are a arr3 not wtrolly
_ dt1Zr'
d FUMM
/
Siprrad an its date: � � �,�---i-----
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DispoWm of Cnerrraoad ROMOft
I hereby direct Pine View Crapratar(rrrn b dispose of the cremated rerna4rs as folraws:
Mdl to
Other arrangemerds-Please apeciy:
ff AkWWOM of areereted retrrfs Is requested.ctredc here
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Rgvislom Jarnmcy 1.2M
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