Molella, Dorothy .4� o� OF QUEENBS `u-�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name— o{o4l. Hold.,
Case# 370
Date Of Cremation2ov7
Time Cremation Started
Time Cremation Completed q+so 0
Type of Container i5T r
Remarks
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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 authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of
� .Qo-MkA2 -r10UELLA 'Fe mALr,
(Name) , (Sex)
�31 677TAW A S—1 .. 'LAkE Gl✓OKEC I" SA) > m� 4�
(street) (city) (State) (Zip code)
who died on (o day of A U G s-r- 2oQ`i
LAIve, QuEENsc3u�y�'1� tag-o}-r-
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
v2AV\kEI- 1Y\oLELL6 A. Sc.N OL S-1 LAk oy--G-'-n 0
ter' (Name) (Address)
Relationship to the deceased S.n to
Name of Funeral Home 'S-'TA47�0?-JC7
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (hes no) maker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device In his or her body.
I certify that I have full power and authortratlon to arrange for the cremation 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
save harmless Pine View Crematorium from any and ail claims and demands for loss or damages whk:h may be made against them
by reas9p of or connected with the lion said remains as directed,whether such claims or demands are or are not wholly
groin ,false or lent.
(WKness
) ( )
:kyl )O �fTl-AkE GEC)R-C-E)-Y\ 1 a
(Signature and Address of Relative or Legal Representative)
Signed on this date: A cA . R`i a O o l
Disposition of Cremated Remains
I hereby dined Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
other arrangements-Please specify:
If pulverization of cremated remains is requested,check here .162
Revision:April 18,2007