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Mudgette, Geneva
OF QUEE5B NU_r� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director ��- Name_ ..Q ne y� M ut�G[he Case#. C12(� Date Of Cremation Gc4060r K Z©01 Time Cremation Started . 3 Ati Time Cremation Completed Type of Container u� ,,,� Remarks M A TO 1: 4 D ovr Y 1S (a0L t; : (4U, Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury,New York, 12804 Cemetery Office:(518)745-4475, Crematorium:(518)745-4477 Auftnization to Cremate The wowsWed rewests and authorizes Pine View Cwrialmurn.in aowrdw"with and ajbpd to its Rules and Regulations to c remde the remains of: (Nan*) l I Z 7 T JSc-U �' /2_ 3 (Street) (city) ( (Zip Code) who died on � (* O CT"�'V,— 20_0� -7 Name addrnss of nearest relative or ne me of person (Nam) (Address) Rip to the deoeased S _ Name of Funeral Home • ✓`�(L I rgxgs APIT: i the daased(Is) (f>Ers rw) emaloer.defibrillator or arty other battery operated tepreserd the to the bit of my imoMAedge. eo device in his or hex body. (Cmde Ono) I Car*that I iraee fur power and suftwiaetion b arrecge for go ceecrredior+of the remains and to direct the disposbon of the cremated remains4 to any persaad poegasalwo hwae allim been amoved or may be destroyed.and agree to protect.defend and sere harrrrless Plus View Cpwnelarflan tom any and all claims and decaerrdsfor lows Or daerr 10es alridr may be made against Orem by reason of a ith w thea�errrMN I of said cornetts as dreck4 w wilim such gains or demands wo or are not wholly C/JTb (Signet"and Address OFar ) Signed on this date: Disposition of Cremated Renreins I hereby direct Pine view CreffoWdum to dispose of the cremated remains as fofiom Mato pfiw arrangemeM-PleSISe specyy: If pulverization of cremated remains is requested.die&here Revision:January 1,2006