Shadick, Marjorie OF QUEE9 5BUley
PINE 'VIEW CEMETERY AND CREMATORIUM
QUAXER ROAD, Qi,JEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Name
Funeral Director /}K -
�i`� r 'o�; �a Sr4cl1c(� Case#
NHS
Date Of Cremation UC{') n b 31 Zoo
Time Cremation Started
Time Cremation Completed
Type of Container �rt(�oF,�(� � NP CA SF
Remarks
Ml� (v
I40J / `1opm
P`. �OQI"
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804 ,
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Audxwizo*m 10 C11611INS18
The u d requests and authortws pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate f:
/the remains o
/ k_
(Name) ( )
7 J(� Gs sQAJ L /ZPoAt
(city) (stow Mip Code)
who died on i`�I (�L� day of. 20
at
(Place) ( )
Name and address of nearest rm relative or name of person authorizing cremation: SU�'/- y2^�
el -
(Name),S �r (Address)
Relationship to the deceased /A_)1 C-47G L-f
Name of Funeral Home / 1� /
IMPORTANT: the deceased(has)or(has no)pacemaker,defibrillator,battery.battery pack,Povri
I represent that to the best Of my knowledge,
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that 1 have fuN power and arshortwtion to arrange for the ctemgdon of the remake and io direct the disposition of the
cremated remains6 that any personal possessions have either been reproved or may be destroyed,and agree to protect,defend and
save itanNess view fta raelm calakileim as erected.vino 'suc damah ges de ich tdssaam orr aerie 89099 them
not wholly
by reason ofected with cremation
(Witness) (Add )
OU1�`
ngggg of Relative or legal R ive)
Signed on this date:
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
other arrangements-Please spedfy:
if pulverization of cremated remains is requested,check here
Revision:April 18,2007