Byron, Dorothy rt
TO O
F QUzPWE YIE ����B
W CEMETERY AN
QU R ROAD, QUEpNSBURY, CRNEWEMATORIUM
YORK 12804
(518) 745.4476 (518) 745'-4477
Funeral Director 2
Cased �13
date Of Cremation
Time Cremation
Started
� .OS
T ! rne Cremation Completed
r
Ty ?e of Container
Remar',cs
Town of Quewmbtxy
Pine View Cemetery and C r+ematoritxn
21 Quaker Road,Queend uy, New York, 12&9
Cemetery Otiioe:(518)745-4476,Crematorium: (518)745-4477
Audwrizadon to Cremate
The undersigned requests and eutimizes Pine View Crerrrelorirsn,in orcordenca with and subject to Ifs Rules and Regulations b
cremate the ren ft d:
T-bk'o7-H y
( 18m) � >
y31.S -5�?L-tTo s'W Rr- f�D' , PAPI-fy NY 12-U5
(street) (City) (state) (LP coda)
who died on 2S'r H cby 20e-'
at A41314^ly >lil ,--41- C'r1v742. Al ravy /V`/
(Piece) 04dresi)
Name and address Of nearest living relative or name of person aultwrb"crentador r
T M F5 �vl -�� 43g5 So of �i Rv2 ytADry Ny lrAl✓oy T3 y Zo^v
(Nom) Viddress)
Reledonship to the deceased X
Nome d FurterM Fim, kjEZ )6: ✓—�IJZA L J-/0,,tl-1, //V G
IMPORTANT:
I represent drat to On best of my ivtowledge,the deceased(has)or no delbrMolor.bettery.battery track.Power
cek rodioacdvs krtplertt or redkxvMve device In hk or her body(
l cent y dmt l have tuN power wW aufltorWoon to anartge for"cremation d the remains and to direct the dkpoeidort d the
cremated renw",that any p o on al poesessiorts twos either been removed or main be destroyed.and agree w Protect dafertd mid
save hermises Pine View Cnwwiorkrm from wry aM ON All ms end demands br loss or dernsges which n*y be made apaktst them
by reason of or coratected wiUt the crarnOlion d said rerneirts as directed.whatlter such ciekrts or demands area ere not wholy
'� ✓� FW
(Acidness)
60-� <A-E A5 AAotlf
/-MbnatUre Old Address Of PA"M or Nepal Represen adve)
SOW on this dole: /2`S/0
I
Dkpos w of Cremated Remakts
hereby dkerx Pine View(crematorium to dispose of the cremated rerrtairts as blows:
Mal to
Other anargernerils-Please spedfy:
ff pulverization of cremated remoks k requested.cFteck here
Revision:April 18,2007