Gill, Schuyler F `
TO WN OF Q UEENSB UR l�/
Pier Virtu Ce»ielery nttd Crematoritt III
11 Qunker Road, Qtteenshttry, NY, 72804-5902
(518) 74 5.44 76
hIrP:iiww%v,queens bu (518) 745.4477
bury.
Funeral Director:
war
Name of Deceased: 1
Case Number:
Date of Cremation:
CC)
Retort: �c-�cE f�✓ C��(._
Time Cremation Started: i Z .q 0 Yi
Time Cremation Completed: Lir
Type of Container:
Remarks:
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• �C '�h tiU �1`'I
Z l �1
" Hor,te Natural Bea it I ... A C Pfarr to Liue "
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 aulhori ies Pine View gym,in accordance with and subjW to its Rules and Regulations to
cremate the remains of:
S"- hit i , Ie,r
{cam {sex)
( � (CRY) (state) (zip Code)
who died on 19 day of U O -f 200
at Qa asp l+a I
(Ph") `T {Address)
Name and address of nearest VAV reloft or name of person atdro t ft cremation:
�A(` ill r Q-1 Gb4 I fr- 12 r i nl
Olam (Address)
R to the deceased j
Name of Funeral Home
IMPORTANT:
1 represent that to the best of my Ionowledge,to deceased(has)Oues no) or any o0w balteny operated
device In tds or her body. (Circle One)
1 certify that I have full pourer and a gwrlimdon to arrange f ect the disposition of the
cremated remains,that any personal po�essions how either been ramoaed or may be destroyed,and agree to protect,defend and
save hanrdess Pine View Crerrretortum taotrn array end all claims and d, , -1s for loss or damages which may be made agatnst them
by reason of or oortnectad wRh the creomdon of said remains as directed,whether suds claims or demands are or are not wholly
false o7t�
�
Mftrless ( )
Address of Relative or Legal Represeraative)
Signed on tMs dalm d2 b 1 O
Dorn of tad Remains
i hereby dire&Dine View crematorium to dispose of the cremwed remains as follows:
Mail to
O&w arrengemerks-Please specify: T U 4 Yam' --
If pi on of cremated reams is requested.check here
9
Revision:Jamory 1.2M