Allard, Lena OF QUEE9\�50urR_T
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 128N
(518) 745-4-476 (518) 745-4477
Funeral Director &EJ(A�}J�k�
Fame llnS
H I) Case# �
Date Of Cremation
- Z�( - p
T L m e Cremation Started
Time Cremation Completed 9*1K-
Type of Container
Remarks
12 5/}
d: soq�7
Town 0#Queenshury
Pine Yew Cenmtery and CrematDrium
21 Quaker Roast,Queenstmi",New York, 12WX
Cerne%"4f(i4;e-(518)7455-4476,C'As m"rkm-(518)7 7-7
Auftnizabon ID Crime
The uFWMftW MQLAM OM alllofts RaView fie,ineoemOffimevft end x ro vas R>ft and RepAitorsto
cremate the romairm of
�EN/) c /')ii-o n9 F En+9tL-
(ftm) (sex)
0 to t2r vTL 2.9 c2ECoT
(street) (CIt9) (fie) 90 Code)
who died on / day of �► 2D G,
O (Ad*e'w)
Name and ad&ess of nearest iivkV retafw or name of person autivarbing crernadom
(Add) ,
Hetatiortshtp to the deceased So Al
Nan*of Funeral(-tome �r,�xd-O m - .�'24cr2.
IMPORTANT:
I represent that W the best ot my kvwWM the deceased(has)or Q=no)peow .aker defbrillainr,bstery,battery pack,power
oeli,radioactive anPkW or rafoacive device to his or her body.(Cb de One)
I certify drat I have fun t'Df ft rt end to r the v on Of the
cremated regaaisrs aryr pus®e love efthff rsaploved or afty be An gh ml w and agree to protsct,defend Mid
9 Pine Vlow from any and ag dat oW61 1 liforloworlen+ages vd"may be matte agathst fhem
of or cormeced vo ororaod a of said as der I whether suds calms or demands aro or are not wooly
.�grorxd4ess,taR.se 40rlpn6`uherst.
,>.r
(§biaue and orb )
Signed on this date. / 7 ' o IT
ulsposition of Cremated Remains
i hereby aired Pine view Caremiak hen to disp3so of the cremated remains as foams:
MeA t0
other wangemerss-Pheaw specter_ ��� W!� A old
If prrivermation of crotnated remem is reWeMc%check two
RevJV1on:4pM 18,2007
Rutes—4 Reg.-ati-m
Rtn;;!Mew Crematonum, is lc<:8tPd On tt�e VrOt"Ids Of P-n-91 V!'-mw- The
ef?
a rranno em—enm for the
is nec�-7---6AL ts
zXd r �staung
i aasc E me n's All MMA
_rs
FC= ITCAM tilt-;
e any remains wal De
r72 hm m!of ror-p nt r-w,
h-e men--I VIR Ren.!;ftp!pe
Cre!MtM. Ad4M
Adiflt
( iron
fene 13 months to 12 vaaral I.ClRn An
Saiur6av 0-p-mabons