Kelleher, Joseph OF QUEEVBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director S �
Name Jo.- e0), Kp-[W of Case#
Date Of Cremation `7— ly — O L
Time Cremation Started (( : U(,, Ar-1
Time Cremation Completed_ q'30 9
Type of Container hlc'c)'� C4S✓t-1 CgAWFOP-p ts; L?iSr
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The md�requests and a gwims Pine view Crematorium,in a000 ndarm with and aLMW to its Rules and Regulations to
cremate the remains of:
( ) (Sex)
2S M/ 12-F a /
_. (street) -- (city) ( ) coda)
who died on ` ' 7 day of YO! 20�
at (�� JV?A—
Nome and address of nearest tiring relative or name of person mation:
s! /� '6u L}/�vk �S �cre
(Name) ( )
Reiadoriship to the deceased
t�
Name of Funeral Hm oe / / � � r�
IMPORTANT:
I represent that to the best d ON browledge.the deceased(has)or no oemafaer,deilbrillow or any o9w betldry operated
device In his or her body. (C kite,One)
I certify that I have full power and alAwrizaHon to a rOW for the aernatbr►of Clue rernahra and to direct the disposition of the
cremated remains,that any personal possasslorts have either been removed or may be destroyed.and agree to protect defend and
save hemniese Pine view Cremstork m from any and aM claims and dernarnde for lose or derrnages which may be made agairwt then
by reason oforconrodod vAh the aen edon of add iamb as drecled.whether such 111 dr demerits are or are not wh0NY
groundless,Use or
( (
(S00It a and of Relaure or t�egal�)
signed on this date: � /.�/0
Disposition of Cremated Remains
I hereby direct Pine view Crematorium to dispose of the cremated rerrraim as follows:
Mall to
other arrangements-Please specify:
if puiver[zation of cremated rerrneins is requested.check here
Revision:January 1,2006