O'Leary, Edith i •
TO
OW N OF UEENSB UR Y
Cemetery and Cremalorium
21 Qunker Road, Queensbitry, NY. 72804.5902
(518) 74 5.44 76
htIP:Il` %v%v•queensbu (S 18)745.4477
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Funeral Director.
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Name of Deceased:
qr
Case Number.
Date of Cremation: MCI7�
Retort: r' �v �
Time Cremation Started:
Time Cremation Completed: tic/ :: z
Type of Container: e.re�Johfrtd
Remarks:
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Horne of Natural Beauty ... A C0011 Place t
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Town of Queens6urry
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12WK
Cemetery Office:(518)745.4476,Crematmium:(518)745.4477
Authorization to Cremate
The undersigned rawmais and at*wrhw Pine View Cmnmwrkn%b accordance vnah and s t od to ft RWea and ReWedons to
cremate an rema6u of
Ed (+i-) D 'Le—�Y1 1 Fc/Yla i c—
(Nam) (serf)
(ftw) i (Swe) (ZIP Qx*
vdw died on I ^l day of U a,N 20 0 8
at Cn f-
O O
Name and addraas of rteareat ivft eefattve or name of peiw a shortig c ernelion:
(mow) (Aftess)
Relationship ID I
Name of f-um"Moms y a tp=�,r E't.�.y1k-►l +-6 YY1—
ra that logo best of ay knowledoe,the deoeaeed owe) ar any aetar baftary aperalad
devioe in tits or bar body. (Clrole One)
t aw*gat i hove fug povrer and m9wrtaation lo arrange for the-weeft of fhe remains and to d rect the dis poeld r, of the
crud that any peneorwi possessiane trove eltim been removed or may be deli op4 and agree to ProleKx.defend and
save t mtleae Pile 1New from arty and all clslm m and dearonds for kw cr rip l gas vfth Maybe garde apahst gam
by reason of or corirwcted w>6►fie damson of asid rerrtebts as dret�ad.v#jWwr still d l or derrFds are ar ale not
( Sarin of legal Represer*")
Signed on#&dater
Dispasltlon of Crernaled Rama ns
I h eby direct Pine View Cwnslodum to dispo®e of do aernewd renrekw as iolowa
Met1 to
Odwanwwomerrts-Pleesaspe[ify: _ —
H pukwh adon of cremaled ismans is rea wsled,check here
9
Revision:Jammy 1.2006