Hanko, Shirley zO q+N OF QUEE BU(
PINE VIEW CEMETERY AND CREMATORIUM �y
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
rr Funeral Director
Name �l«�t� �I4n�o
Case# �3
Date Of Cremati.on
I r1 os�
Time Cremation Started I�GO
Time Cremation Completed 3'60 Q
/
Type of Container L nIi 4 oar 2M0
or
Remarks
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Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-d476,Crematorium: (51 S)745-4477
Authorization tD Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
Ir 44 11n
( ) / f ` (sex)
�.�+1�,��1�,���,yy�l�l ��+1����f �7{� _
(St� (City) (SM) (ZIP Code)
who died on i` day of I X�(`P CL k r r
(place) I (Address)
Name and address of nearest living relative or name of person au#x=wV cremation:
(Name) f
Reiatkxv;Wp to the deceased
Name of Funeral Home tT e,
IMPORTANT:t represent that m the best of my knowledge,the deceased(has a(hae pacemaker,deftillator or any other battery operated
device in his or her body. (Cirde file)
I certify that 1 have full power and sudwrization to SM91W for the cremation of the remains and to direct the disposition of the
cremated remains.that any personal possessions have eNter been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View CreMS1111itrrtt from any and al dWm aid darltords for loss or damages which may be made against them
by reason of or connected with,dne csernedon of said remake as d hK29CI,whether such dams or demands are or are not wholly
lessl false or frauduierrW '
Y (w ) (Address)
M (Signature
and Address of Relative or Legal Rom)
Signed on this data: P�� ' D'-7 - --
Disposition of Cremated Remains
I hereby direct Pine View C.rmrnawrjum to dispose of the cremated remains as follows:
MON to
Lyu
Other arrengemerds-Please spedfY:
1 1�
If pulverization of cremated remains is requested.ehade here _
Revision:January 1,2006