Wilbur, Francis OF
P QUEENB U,�
WE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSSURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name I ' Ti��SU�.
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Case# -'j�3
Dace Of Cremation
Time Cremation Started
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T : me Cremation Completed
Tr ?e 01 Container
Remarks
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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 u xWrsgned requests and suft(tzes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of
(Name) ( )
2 v '7 pi lee 'ja 6d/c- f�f C l�r�srs AJ,Y. /dr/
(�") (City) (state) (ZIP Code)
who died on S day of '( 2Og2F
at vet"Ty
(Place) (Address)
Name and address of nearest living relative or name of Person authorizing cremation:
�cV/T//,'Lcllc�ill y
(Name) (Addreae)
Relauonship to the deceased
Name of Funeral Howie ✓
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pecernaker,defibrillator,battery,battery pack,Power
coil,radioactive implant or radioactive device in his or her body.(CMe one)
I certify that I have full power and authorWrtion to arra
cremated remains,that any personal possessions hav nge for the cremation of the remains and to direct the dspostton of the
e either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for loss or
damages which may be made against them
by reason of or connected with the aemation of said remains as directed,whether such claim or demands are or are not wholly
groundless,false or fraudulent.
Z �;( �e
and ess of Re eaRepresentable)
Signed on this date: Y2
Disposition of Cremated Remains
I hereby direct Pine View C rwwtorium to disp/oae of the cremated remains as follows:
/D
Other arrengemerns-Please specify:
If pkdvertzation of cremated remains Is requested,check here
Revision:April 18,2007