Mija, Nancy A
lOMIN OF QUEEN,5BU,(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(5 18) 745-4476 (5 18) 745-4477
Funeral Director 'ARLr-
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Name I Case#Ctncti I'1 �, _ 3 1
Date Of Cremation — Sf - Gtb
Time Cremation Started_
Time Cremation Completed
Type of Container ������ rr.L ,A rd tc j A
Remarks
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30
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35�
Town of Queensbtwy
Pine View Cemetery and Crematorium
21 Quakes Road, Queensbury,New York, 12WA
Cemetery Office: (518)745-4476, Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In 0000►dance with and subject to its Rules and Regulations to
cremate the remains of•.
Nancy Lee (Wright) Mija F
12 Oak Hudson Falls NY 12839-
(Street)09/04/2006 (City) (State)
(zipC�&)
who died on day of 20_ _
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living re[adve or same of person aunlhorbdng cremation: --'-
Andrew Mija Apt. 2, 214 Main �w %r �;
AL.�
(Name) (Address) `
Relations*to the deceased S o n
Name ofFuneratHome Carleton Funeral Home, Inc.
IMPORTANT:
1 represent that to the best of my bxwAedye,the deeeeaed(has)or(has no)pacemalatr,del b illator or any other ballay operated
device it his or her body. (Ckde One)
1 certify that 1 have U power and authorization to arrange for the cremation of the remains and to direct the ftposltion of the
cremated remains,that any persons[possesskm have either been removed or may be destroyed,and agm to protect,detbnd and
save hanf*m Pine View CtmrraUjum*om any and all dai ns and demands for kas or damages vA ich may merle against ahem
by reason of or conrecied with the of said remains as directed,whaltar such Claims or danvmnl--7/
not wh*
false or froudulanl. 8 -'�
2_ ( )
(Signaw a and Address or%elative or Lead Representative)
Signed on this date: -7 , 000�
Disposition of Cremated Remains
I hereby dived Pine View Crematorium to dispose of to c ernaled remains as foYows:
MON to
Odner ernanpemerts-Plasm spediy:
if pulveraation of crenated remains Is requested,check here XX
Revision:January 1,2006