Fleisher, Alan OF QUEEN
l.1 2�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director L7Lti5►joRE
Name El el5Lc
Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed 10
Type of Container fil"Qlfc) i
Remarks
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MAT IJ
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i
LI31
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 undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
L ,�a I Lei
(sex)
l-I� �R� � lu s
(Street) (/ (City) (State) (Zip Code)
who died on 0 day of 51 _ 20 d b
at 2 a S— 1 _JAJ fl k % f
(Place) (Addy
P11 --AA ii,>ing relative or name of person authorizino cremation:
(Name)
Relationship to the fe-
Name of Funeral Home G'^s" ' -+1 Ae
IMPORTANT:
I represent that to the best of my Wvwledge,the deceased(has) has no) defibrillator or any other battery operated
device in his or her body. (Clyde One)
I certify that I have full power and authortration to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
false or lent.
111-f �Sn>R �S�\efM e C ar
/ ness) (Address)
(Signature and Address of elative or Legal Representative) CEFERINO R.VILLAFUERTE, M.I,
ADIRONDACK CLINIC
Signed on this date: / ZOQ SMITH DRIVE
R(NTH,NY 12622
t '195W
*'A Al
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
Revision:January 1,2006