Clark, Kathryn QU rE
L B. B
PLNE ',qE?' CEMETERY AND CREMATORIUM QUAKER ROAD, Q(JEE,gSBURY, NEW YORK 17804
(518) 745.4-476 018) 745'•44477
Funeral Director Kc �4
game K�t �� Cleric
Case C(A
:ace 0! Cremation
^ e Cremation Started
Cremation Completed 10120
o ,' Container ("wry e iA S fZ
remarks
MkId 7, S /
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Town of Queensbury
Pine Vww Cemetery and Crematorium
21 husker Road,Queensbury,New York, 12804 ,
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The txderaigned regLm%and auvwrtms Plne View CleNWwkxn,in accordance wth and subject to Its Rubes and Regulations tO
nj
rtij Asee
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Sereei)
--- (city) (state) pp Code)
who died on
- d c)0 c_ 20 4
at (Ph") (Add ran) `!
Name and address of nearest living reAUM or Warne of person Whortclng CrW7
h (Address)
Reletiorwrttip to the deceased
Name of Funeral Home IMPORTANT: the deceased(has)or deabriMaAar,battery,battery pack,power
I represent that to the beat of my ic,owledge,
cell,radioactive WOW or macective device in his or her body.(C*cle One)
I certKy that I have U power and&Ahwkadon to arrange for the crarrradon of fhe remains and to direct th ee to dispproosition
of"V d and
cremated ramakrs,that any personal poseessions have elther been removed or may be destroyed,
and save hamdass Pins View Crematorium trom any and all dakra and demands for loos or damages which may be made 69w*them
by reason of or connected with fhe cremation d said remekts as dkeded,whedwtr such claims or demands are or area not w"
gnpundiess,take or fraudu*t.
r /
C C 2 yq �� P a A . /9yK5
(Signature and Address of Rebtive or lapel ive)
Signed on this date: d-v'a
Dispo Ww of Cn"ad Remains
I hereby dbect Pine View Crematorium of� as follows:
Mad to �A / 177 C
Ode-arrangements-Pbese spedfY:
If puivertsation d cremated repWns is requested,dteck here
Revision:April 18,2007