Goodson, Marylou OF QUEEVBU.�.. y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEErNSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ 12
Name_ I�a��, L-v Cur-,(I so„
Case#
Date Of Cremation cl_2i_06
Time Cremation Started 11' 36 r
Time Cremation Completed
Type of Container Ch j, u�J '
SST CA Sri
Remarks
MA i)
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3 1�1y
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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 mWersoied mWeSIS and au 0dws Phe view Cm=Wfkn,in accordance with and a d*d to its Rules and Regu{etions to
cremate the remains of
=
(SOX)
r6,Q 7 C Ci2 F3L_ l" " ) �'��)
O
who died on _� day of �L1P i e /2 �20 CCU to
at C L Lf.JS r1 �S f l/1L
( ) (Aft'm)
and address of newest*AV relative or name Swp 7milon:
)gp
(Name) (Address)
ReiationsW to the deceased. AIVJ
Name of Funeral Home
IMPORTANT: the deceased(tras or(ha�wwiakm.
r a arry or betty opted
I represent 00 In the best of my latowledge,
device in his or her body. (Cide One)
I cerW that I tWM fun power anti WdWrization to errertpe for the awnstion of the wins and to direct the imposition of the
c mnMd remains,that any pers"I possesskxu have either been removed or may be destroyed,and agree to protect,defend and
save harmlesspke View Cremalwkm km=WOWd�s dkeciA wheUier such�oror demands are or are not wt"Y
by '
77L/
of7�`�"�
ReaeritetNe)
signed on this date:
Disposition of Cremated Remains
I hereby direct Pine view C:rematodum to dispose of the cremated rends as follows:
Map to
omen arrangemerns-Please spedfy:
if pulverization of aremated remeirrs is requested,d,edk here
Revision:jam ary 1,2006