Pilon, Coral TOW7� O
.T QUEEN'r
FINE "r'EW CEMETERY AND CREMATORIVM
QU tiYCP3t ROnD, Q(IEENSBVRY, NEW YORK 17804
(S18) 745.4.476 (518) 745.4�77
Funeral Director
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NUMBER CREMATION ORDER
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The undersigned hereby requests and authorizes the Proprietors of then=Cemetery in acoortwee.with andsubject
to its rules and regulations.to cremate the remains of the following person:
tl�a1�... :.....`,. 1N............................................sez� - Si :::::::::::
at.... o'clock..._......on the 5 day of. '•4 �kl....... ..... �Q ....agtdq.q!.•years ....morift ...days
Death due to infectious or contagious disease yes O Now
and certdies and represents that Owy have the right to make such authorizalionxW agrees to hold the Cemeteryhanmless of any liability
on account ofsaid authorization and cremation.and directs that the cremated remains arc to be disposed of in the following manner.
o Cremaint to be picked up by Funeral home.... d-n ,�
Crertlainsto be mailed to....................................................................... -�
ro- Other Disposition:FPRACA7MFNGS SEE REVERSE SIDE ...........,..................................
Signature of Next of n ... ..... [ ..............................................
Relationship to Deceased (or Authority to Sign) .} .._............ .._...
Address .�. a!! .. �5c�1,� e,+ ... ........Street
Date of Cremation ....... ................... City...l•_ `o� .i. .....Q��.S�Q.-�eatr-..............
tiHour of Cremation ..... .. . ................M Receptacle.. .......................................
N Funeral Director t e` .... .� ..t''.� ..Z L.Q...N- �eN..�� Ea ssir [i a f �*►i a�
The cremation process is by no rsteant"final Dlspoutloe and memoriaiizafion of cremated
remains through an appropriate memorial location should be completed at the same time as
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funeral arrangements.
r —PLEASE READ OTHER SIDE—