Gilbert, Mary OF QUEEN,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Mrs k, �►„��
Case#. 336
Date Of Cremation / „ 10 ? obi
Time Cremation Started g: 3�
Time Cremation Completed 1017a �Ih
Type of Container_�
Remarks
tiATw X : ya
U7
�1v 11�
:o: Iv�
_ cVL 16. �ftilmer Auneral �hime �l
6401 Main Street 82 Broadway
Argyle,New York 12809 Fort Edward,New York 12828
Phone(518)638-8216 Phone(518)747-9266
CUSTOMER'S DESIGNATION OF INTENTIONS
FOR DI SITIO O REM ED M NS
Full name of d ased w 4
� ` Masse PRINT Name)
]1\` J,/� SCHEDULED PLACE OF CREMATICAN
119AC&ILED OATE OFCREMATION
The undersigned person(s)making arrangements request the Disposition of Cremains as indicated below:
( J Interment or Inurn nt
Won —WAI� PLACE OF INTERMENT OR INTRNMENT
[�) Release to:
SPECIFIC NAME
[ ] Ship to:
SPECIFIC NAME
STREET ADDRESS CITY&STATE
ZIP CODE
[ I Other:
I(we)hereby represent that I am(we are)of the same of nearest degree of relationship to the deceased and/or are legally authorized or charged with the
responsibility for the final disposition of his/her body,and that the above are my(our)instructions for the disposition of the cremated remains of the
above named deceased.I(We)state that I(We)understand that the cremains of the above named deceased may be disposed of in any lawful manner by
the above named funeral home,if said cremains are unclaimed after 120 days from the date of cremation.
Dated this 14 O� day of I/T QK.oy" 1 g
/+�/ MR.
�'S �\ MRS
miss
�t n MIS
IligJAITIE
�ALOI9TERWAY 1,1 Address
GREENwrCH
City and State —�'�` Zip Coda City and State
Zip Coda
Phone Number
Phone Number
The undersigned Funeral Director attests to the following:
(1) If the cremated remains of the above named deceased are unclaimed after 120 days from the date of cremation,said cremains will be disposed of
in the following manner
(2) A copy of gfi Design t n f Intentions was given this day of to the pers ( r nts for remation.
Signature of Funeral Director Making Arrangments Printed or Typed Name of Funeral Director
The funeral firm's copy of this Designation of Intentions will hereafter be completed to show the following:
Actual Dale of Cremation Name of Crematory
Address
City and State Zip Code
Date of Disposition of Cremains Location of Disposition of Cremains
Manner of Disposition of Cremains:
I
Dated this day of . 19
Signature of Person Making Disposition of Cremains Printed or Typed Name of Person Making Disposition of Cremains
TOWN OF UIIEENSDURY
DINE VIEW CEMETERY ^
A !V�
CIIEMR UIIIUM
Qualrer Brad, Queensbury, New York 12804
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AU1'I IOR I m y ION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cr mate the remains of :
(Namur (S 6Ia.MARY'S CONVENT
CLOISTER WAY
KREENWrrru A_ -
(Street ) (City) (State) (Zip Code)
who died o day of
at _
(Place) ( duress )
Name and address of nearest living relative or name of person
tho izing rematio :
lAW111") , C-341
a&(Name) (Addrau )
u
Relationship to the deceased 11'u
Name of Funeral Home
M. B . Kilmer Funeral ome
IMPORTANT3
I 7emaker
t that to the best of my Knowledge, the deceased has or
as no in his or tier body. (Circle One)
I certify that I have the full power and authorization 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 all claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
g undies f Ise r raudulent.
_ ��
(Witness ) (Address )
(Signature of Relative or Legal kep. and Address)
Signed on this date :