Sigler, Susan 70� � OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case# 3k
�y
Date Of Cremation
Time Cremation Started "7
Time Cremation Completed (01 ,) &
Type of Container
Remarks
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Town of Qtmensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queertsbury, New York, 12804
Cemetery(Mice:(518)745.4476,Crematorium: (518)745-4477
Audwizodon to Cremato
The undosow requests and authorizes Pine view Cremator jm.in accorclove with and subject to Its Rules aril RewAaft s to
cremattt��e the remains of
JUSAN S )CiER. ( r)
(Name)
26 R,vckST,
( ) (C*4 v (State) (Zip Code)
who died on day of 20
at
O O
Name and address of nearest releidve ar rrarrre of person aulFro tft cremation:
(Name) 1( )
ReieftW ip to the deoaeaed- - G 6-Af l7 Art rQ,c
Name of Funeral 1 kx,m 1 M 1 Ayrt!AftA D KII'2 ra even 9 L
IMPORTANT:
1 represent that to ft best of my knowledge,the deceased(has)or des eo)Pecenu*w,defrtll m or arty otlrer bafry operated
device in his or her body. (Circle tine)
1 Cm*drat I have full power and acrtltorization to wrow for the cwem n of the remains and to direct the d woomm of the
cremated remains,thst any persorrel poseessiom have either been removed or maybe destroyed.and agree to pr+cle A defend and
sable hwffftas Pine view Cn n WrWm from wtir w d al r'Ni I s and damanda for toes ar dernages which may be made against them
by ream of or oomec7ed wkh the aonation of said rerrrairrs se directed,whelfor such c ms lai or demands we are or are not wholly
gro
L _
(Address)
(Stg Vkft Address of �)
SOW on this dote:
Disposition of Owneted Remains
I hereby dared Mine view C+enrMdtun to dispose of the awmftd remains as follows:
MON I
I
carerarverg merMa-Please apedfy:
If p0 erh ation of cremated remains is requested,check here
Revision:.brruery 1.2DOG