Fagan, Francis OF QUEErV50ur,�
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKF-R ROAD, QilEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director MI11p�
Name FrehC15 �hiq
C a s e# b�
Date Of Cremation I_ 30 Oca
Time Cremation Started �; ZU
Tame Cremation Com
pleted-
TypeType of Container
Remarks 5
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authormes Pine view crematorium,ai accordance with and subiect to Its Rules and Regulations to,
cremate the remains of:
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(Name) ( )
Rk �53 3o Blue M-6g LoX!,, &DI Id Sid
( ) (City) (State) (Zip Cam)
who died on 2-' day of sn.h u n.n. 202
at c- ",, its 1 CGIr_ ir,-Fr.115
(Place) T (Address)
Name and address of nearest living relative or name of person authorizing cremation:
11l A QLi
ame) //1� (Address)
Relationship to the deceased W (-i-e.
Name of Funeral Home M I.IP r re rA I 44nny,
IMPORTANT:
I represent that to the best of my lolowledge,the deceased(has)or(has no)pacemaker,detbr NSW or any other battery operated
device in his or her body. (Cirde One)
I Certify that I have full power and authoraation 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 daims 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
- (Address)
-7M
(Signature Address of Relative or Legal Represented")
Signed on this data.
Disposition of Cremated Remains
I hereby direct Pine view Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:rr ie Se- 4D -f?. &lira 1 h o►ti,—
If pulverization of cremated remains is requestei:1,dhe&here _
Revision:January 1,2006