Monteleone, Frank Jr. OF QUEE9�5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QtjEFNSgURy, NEW YORK 128a4
(518) 745-4476 (518) 745-4.477
Funeral Director_
Name_ rc,nl( I I0gb ICo >
Case# t�73
Date Of Cremation -1
Time Cremation Started roo, 20
Time Cremation Completed 3; nM
Type of Container
Remarks
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Town of Queensbury
Pine View C mastery and CreniaWum
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Audwizabon W Cremate
The mWersigrred requests and authorizes Pine View Crematflriran,in scoordaros with and subject to Its Rues and Regulations to
cremate the remains at:
irr��k T MOrjte. or,e S Min tC
(Name) (SWO
z� RI \t;y-,,AfLA) St ieoS
(Street) (cry) (State) (Zip Code)
who died on ► , !_ day offj C s 20�
at C-2Lk3S IrL�LDS t(t3`�c�� t-tl I
(Pima) I (Address)
Name and address of nearest Nvirrg relative or rmmre of peraon sewrbkv cremadom
L i Se mount
(Name) (Address)
Relation pf to the deceased,y A"q e r'
Named Funeral Flome L +'
IMPORTANT: dellbfiator,battery,battery Pack,Power
I represetrt that to the best of my kroMAedge,the deceased(has) D)P
cell,radioactive nrpland or radioactive device in his or her body.(Code One)
I certify that I have tuft pourer and autlwftedon to amartge for the cremation of the remains and to direct the disposMm of the
cremated remains,that any personal possessions have e0w been removed or may be destroyed,and agree to Pr'Nt•defend and
save harmless Plan View Cremetorlrm from any and al Anima and demands for iom or damages which maybe made agent them
by reason of or connected wM the cremation of said remains as directed.whether such claims or demands are or are not whotiy
groundlem Wee or trallidulem
(Signakm Address)&Re"a Legal ) /
signed on this date: 1 N12-7
Disposition of Cremated Remains
I hereby direct Pine View Cremratorkrm to dispose of the cremated remaft as fotbws:
Mail to
Other arranpemainds-Please specify: r C I CO Se 4 n G O- r Ol( h o '
If puveri mdm of cremated remains a requested,check here
Revision:April 18,2007