Scoville, Dale �O � 1
—T
PtNE Y(EW CEMETERY AND
QV'A'-,V-P-R ROAD, CREMATORIUM
Q�P.NSBURY, NEW YORK 12804(518) 745•4476 (518) 745•,4.477
_ Funeral Director �Cl�Coy. Ca S e r
= a '. e Of Cremation a��
Jil L Zov
"e Crematlon Sca - td
_ e l2•.0v 12
^� Ctema � ton Comple � ed
=e of ContatneC
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07103/27T 14: 1@ 4 Pgft E E11
Town of Queenstwry
Pine View Cemetery and Crematonum
2A Quaker Road, Queensbury,New York, 12804
Cemetery Office: (5t8) 745.4476,CrerrlatotluM: (518)745-4d7I
Authorization to Cremate
r and t��fps View�"O"r in�dwIm with end subiW to ns Ruiss and ReWlatiorts to
The undersigned egt+eete
aMnBto tl'►e+eHllatnt:Ot MA(4-
(sex) l9A n-,,r.{S, �� I'a t jr"
(Street) (CttY)
Nriu fled onl day of
� i 3 J -c.»� �'nr••1�-�--�,�.dd(ess)
►:eme&v address of hwrea GyiK relative or name of pw^w,,au(hWMnp cremation: '\AA U S,✓�
,r1A2: `mac �, e, i34 C Cnw.ti i _ V.
(Mama)
i�►ddt+wl I a
Re4stixieh+p to the daceefed
Name of Funeral Home K 1 �20 s� _N• `''^ i t tJ _._
IMPOATAM. the duceeW(has)or(has no)peownallW,tSefiWiiala.Dewy.battery WKk,Power
,repreWt that to.he beef of my Ivawle ,
cell,radfoeCtiva knplaM or t'ed"alve device in his or her body.(Ckde One)
I certify that I have tuft power and auttoruatlon to arrenQ4 for the cremation of the remttkis and to Oww the diep JOei Of the
Cremated remains,that any perWral Possessions have either own removed or may be dea rayed,and SOMS to probed,defend and
$eve homes Ptne'Aaw Crematorium from any and all dakns and denlende tOt bm Of 6SM8985 n'RtICh may be made book-Oil them
h faeson of a cwrieced with the cremation'of saki remains as dji-coad.whevw SUCK Claims or demands sfe or are not w"
%roundAp.false or fraudulent.
{witness) tHadres) ?
(Signature and esa of Rerative a legal RepresentetNe) I
SVwd on this date, ng `U3
Otspoedw.of Cramated Remains
I,-*Oy dinyot avta view Cremetortum to dispose of the cremated remmine as fotows:
Mari!o A c K f.!y 41 Qp S.s OPu,y4 AA
_ 3 -_leaf, —%-4 irc�c e + C —,t,.y_t c,
Ottwr -Pieaso sowN;
c wtvertratlon of cremated remains is requesiad.Wwdc he,e ✓
Reytskx:April 1 tl,2007