Litwa, Rose 4 • •
OF
p QUEE9�SoUlp
uvEl
VTEW CEMETERY AND CRE
QUAX R ROAD, QUEFJgsBURY MATORIU
(518) 745.4.476 (51' NEW YORK 12804
8) 745-4477
Funeral Director
� q
Fame t BAGt(�
4w
Case#
date Of Cremation
2 08
Time Cremation Started
S US
T :me Cremation Completed
Type of Container
��
Remarks
g� iS
-------------
4 316
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 authorizes Pine View Crematorium,M accordance with and subject to Its Rules and Regulations to
cremate the remains of:
wgreMaL
(Name) (Sex)
JrI i / it2z-
(S�ea0 ( ) (state) (Zap Code)
who died on day of
at S ( �)
(P�)
K�Name and address of nearest Gvft relative or name of person aemation:
U
(Name) Soto
( )
Relationship to the deceased
Name of Funeral Nome Q
IMPORTANT: deft
(gtor,battery.battery pack,power
I represent that to the best of my Ivowiedge,the deceased(ties)or no per•
can,radioactive implant or radioactive device In his or her body.(C )
i cremated
that i have full power and ardthorization to>�� or�f the be destroyed,��,e to p d III direct the disposition�defend and
the
cremated remains,that any eMSI hsi possessions
save harmless Pine View�inorrr any and an calms and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said nwm*s as directed,whether such claims or demands are or are not whoty
groundless,false a
c `V /.2F/7
*L
N
) (Address)
(Signature Address�ofReWlWv;e or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as t4ows:
Mail to
Other arrangements-Please spedfy:
if pulverization of cremated remains is requested,check here
Revision:April 18,2007