Aston, Trudi PINE YI QUEE9\�,5�BUTry
J
EYV CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEpNS9lJRY NEW YORK 12804
(518) 745.4476 (518) 745'.4477
Funeral Director
Nam� —
T vi�I AStu
Cas 1� 3
:a : e Of Cremac e#
l.on
, me Cremation Started go
� • me Cremation Completed
UGLl
?e of Container
Remarks
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Ada+- fl'11
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16S
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery EMiee_(518)745-"76,Crematorium: (518)745-4477
Atiltt wb2titin tD Cremate
The undersigned requests and aulhoroas fine View Crematorium,in accordance with and subct to its Rules and Regulations to
cremate the remaht of:
(Nam) ($ex)
d�a I-- f- MCI v-� iC } (2 3 Code)
(Street) (CM
who died on 1 t o d� —I �11 ��
at CJIL iY I J y L sl ���y���`
(p'�Q) (Address.)
Name and address of nearest W*V rgWve or Frame of person cremation:
(Nam) (Address)
Rekdkwv;hiP to the deceased
Name of Funeral Home^ 4,�SX- :Fw 6'-UA
IMPORTANT: Fq er,de4�r>N�Or or arty other bury operated
I represent that to the hest of my knowledge,the deceased(has) (has }
device in his or her body. (Ctrde One)
1 certify that 1 have ful power and authorization to arrange for the c remedon 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
so"harmiess pke View ad all delm ard dmmwlft for Ion or dwitiges which mgy be nods against
by remon of or connected�crernwilon ftm of ofsaid romp, g drecfed,whWw such deims or demands are or are not wholly
�.or� ��� L,� CY N it
r�ll �t
(Address)
(Signature and Addre�of Relative or t�eoat Repce)
Signed on this date:
Deposition of Cremated Remains
I hereby direct Pine View CreFrratorium to dispose of the crammed remains as follows
Mail to
Other anangemenfs-Plesse specify
if puNwoetion of cremated remains is requested,cued(here
Revision:January 1,2006