Conklin, Marion OF
QUEE-�� 5t3Urp
PW E
VI CEMETERY AND CR
QUAKER ROAD, QUEENSBURy EMATORTUM
(518) 745.4476 ' NEW YORK 12804
(518) 745-4477
• Funeral Director�����,.�
N a m e ��ry4� L41i�lC
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Date Of Cremation
T UL4 30
Time Cremation Started LCX�g
T =me Cremation Completed
Type of Container
hrfl c,;4 Remarks
MOL
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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 authortzes Pine View Crematorium.In accordance with and subject to its Rules and Reguiattons to
cremate the of:
,�l01i &I/<,1jJ
(Nurne) ( )
Z.3 s v- B AY 1'
(Street) (Co _ (State) (Zip )
who died on 27 day of -U Q 20 6P A
at C[,L��S F�s y i° fir. �_ , liy- / Z eo/
(ae) O 1)
Nameuld address of ntearest rave or name of parson authorkhV aemadon:
b&sY- a�Ke'lJ l/d'7 ? / /(,U C a Ny iz�d y
(48e) (Address) y /
Relationship to the dew
Name of Funeral tiornre ( '� r
IMPORTANT:
I represent that to the best of my Imowtedge,the deceased(has) (hss no) maker,dedbrflator,battery,battery pads.power
cell,radioect implant or radioactive davlce in his or her body.
I m*that I have*A power and suthodudon to ananga for the a n e*m of the rernnairs and to direct the disposition of the
a envftd remairs.that arty Personal possessions have eEm been rencaved or may be destroyed.and agree to protect,defend and
save harrdess Piro Vlew Oren ftxlun from Wq and ag chins and demands for loss or damagesvAdd maybe made against them
by reason of or oonrrec l ed with the cremalion of Said nenraits as drecfect, ilvell r su h del ms or demands are or are not wholy
grounaess.false or
7
.u\
—mitness
) ( )
(Signature Address of Reiativ or Legal Representative)
Oft Signed on date:
DIsposWon of Cremated Remains
1 hereby direct View.Crematorium to dLpose of the as folbws:
tulac�to
2 h1
Other anangemerts-Please specify:
If pulverization of cremated remains is requested.check here
Revision:Ap118,2007