Waring, Thomas - 4-J'p 10: 1 4M: >,, ``
06/01/2007 03:55 5187477546 M.B. KTLMER PAGE. 03 -c33
Town of Qu"nsbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queenabtiry,New York, 12804
Cemetery Ofte:(518)70-"76,Crematorium: (518)745-"77
AuthorizadOO to Cremate
The urtderstpned reQueees and suttta'I>w:%Pkta View Ctamstorw m,In eaoor+0anoe with Br4 fUOJ00 to hs Rules and Regulations to
oremete the remains of
(.tsa�frc;q
�s1� gie Rf le, N
(City) ( ) (Zip Code)
(Street)
who died on T�tat 5#- day of �, Z r U 1
al Glc" F Its os s l ) l
cam► �
Name end eddrrese of e00"Nvktg ceiattee or nerve of POMP Jt*dzkV w6-1 � N/ , YCA4 r��
{ �) ( )
ReWonaft to the deceased. A f4 r eY
Name of Pexterol home_ +=v �u,rtie
IMPORTANT: ddceeead(has)or(Ras no)pa,csrrteker,dstlbrilletor.be",battery peck,power
Wrepreesnt drat to#0 best of my�0*1wap
cell,radloecM impigni or rodk ecM devtae in hts or her body.(Ckde One)
t CertMy t11st I have tuN pov+er and sue rkuthn to sffwVo faf the Gwmaion of the Tama"and 10 dbeol the diapo9Rion of dw e�
i owif # I I have that any pereor+et P We tun s�1e1r bean removed or may be dadIVYed,end 99" PMW. vend
save hamrles9 pIna View Crematoria m trom any and 04 cow tartd demands for well or dattnagas w"my Ibis made agete�t
by reason of or cony eded with the cerrtet)on of said rerttaits ae Sucui d,whWW such daims or donands are or are not wh*
wour0a",terse or haudulent.
(Addrerss)
{�ur�tua RetatM LeQel RepmowdalNe)
Wed on this date:
pigpaaition of Cremated Remainz
I hwebry chats pine View Crematorium to t7lspnse of the cremated remains as MkN4:
--7w f---Mee to J fir. tt�
Omer&Twwmenm-plew" :
If pAerbwdon rA cremated rwDird is requested,&"Kk hate
Revision: April is,2007
OF
PLNE VIER' CEMETERY AND CREMATORIUM
QU&X-F-R ROAD, QVPENSBURY, KEW YORK 12504
(518) 745.4476 (518) 745'.4477
Funeral Director I IC- mcr
Fame i� " ,
—
�°'rj Casein '233
=a. e D ! Cremation
� • Te Cremation Started
Crematlon Completed p ;
;e o ! Container Air ✓W f "d l 1\C,e �
.,.
remarks
06/01/2007 03:55 5187477548 M.B. KILMER PAGE 03
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 authortm pina Vlaw Cremetor{um.In accordance with and subject to its Rubs and Reguletlons to
cremate the remains of:
S(�d,GN0�e�5 �CIY�K
(Name) (sex)
S3 AY !e, /N
(SUM) (City) (Sw ) (Zip Code)
vmo died on S t day of J t,�i�l t� za D2
at Gle,06 F its 0-6 4at t(5 1
T (Place) ( )
Name and address of nearest RAV MISOM a or name of person&AwrbkV crometf«r w t
r&Y"UA 9fd4ard6, ? Wau Sfreef''�
(Name) L ( ems)
Relauorrsftly to thedacaseed
Neme of Funeral Home
IMPORTANT:
I represent that to the beet of my wvwledge.the deceased(has)or(has no)pacer,aker.defibrillator.battery,battery peck,power
cell,rsdloeetNe Implant or radtoadve device in his or her body.(Ckt*One)
I oerttly that I have fun power end a,&Whmt to arrange for the cremeftn of the remains and to tikes ON dispo9Mbn of the
cremated remains,thel any perw Al possessions have either been removed or may be destroyed,and agree to protW.defend and
save harmless Pine View Crematorium from any and aU chime anti demands for kiss or damages which may be made 89MM them
by reason of or oorvwded wkh the Qenvow of said remako as directed,whedw such claims of demands are or are not wfaMy
groundless,(also or fraudulent.
(S /v(1 Relative Legal Represer tiva)
Signed on this date: ' wl/
Disposition of Cremated Remains
I
I hereby direct Pine View Crematorium to dispose of the cremated remains as tonows:
Mall to Mr I k � � Gorr► �u�f.,e�„� _'�
6 j5,
other arrangements-Please specify:
II pulvertzetbn of oramate0 remains is requested,check here --_
Revision:April 18,2W7