Shiell, Robert t •
,1
TOWN OF Q UEENSB UR Pine Virtu Cemetery and Crematorium Y
21 Quaker Road- Q'Itenshury, NY. 12804.5902
(518)745.4476
h((P://Mv%v.qucensbury.net
(S18)74S•4477
Funeral Director: 0 I'll
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Name of Deceased: R
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Case Number. Z$
Date of Cremation: t
Retort Lr"W ue �S G
Time Cremation Started:
Time Cremation Completed: %
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TYPe of Container.
Remarks:
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.. Nome of Natural 8enuty ... A Place to Live "
,&- 8/2H8 10:28 518-732-1287 REGAN&DEW1 PAGE 01
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Town of Queensbury
Pine View Cemetery and C►emato►tum
21 Quaker Road,Queens".New York, 12804
Cemetery Office:(618)745-4476,Crematorium: (518)745-4477
Ruthortzadw to Cremate
The uxiw O-md reWeats and&*Mr¢ea Pine Vlaw CrarnalOftm,in acc*m enoe with and subjw to Its Ruhm and Re"tOw to
(sex)
L,
(CO) (State) (ZIP Code)
# to dkrd on _ C _ r .— day of
le r>parwa 8 Mb or name of
(Name) ;At1d'ess) �Ld'c
Retatbr enip to the decwiwd
Name of funeral Home
MPORTANT:
!reor eswt Vue to the beet,of my ivtowledge,the deed(hm)or(has no)peaanakw,dOROwix f erwy,beaery ww*,Pow
calf,mdioedive implant or radIceah a device in he or her body.(Ckde One)
l c Oy mst then i sWw,1 per and nfBI Or to��iu w been Fwnoved wneOw or mOn ay Cep ed,Wid�w two prcite t, the
deftod and
cxemetrrd rpmainl.that any perhrorlel posoer�iortg
save he n*n fine View Crematorium from any and al cekrle and demende for I=or der wgn~may tw made apaktut them
+xy reown of cc conrtarxed with the avmoWn of saki nww km as dtetled.whodw loch dWm or dwmutdc are or am not rNrunty
� false or trat;Wa tt.
ttnrrnas�i
`I (so wttae and Amen of Rw ouve or tepal Represantauve)- —
Sigr*o on this date'
Liopolitiah of Cremated RwiWm
!hwr by dined Plne View Gremstorlum to dispose of the aornW d 19111 4$e fdiaw6:
Mail to
(ldW amsVements-i WOW"Wify:
if pulvenzation oR creftteted rwuwls is regc 610d,dw&here
RaviSlon:April 18.2007