Orologio, William 0F QUEErV,5(Burp
PINE VIEW CEMETtRY AND CREMATORIUM QU,AY.ER ROAD, QUEENSBURY, NEW PORK 12804
(518) 745.4.476 (518) 745--4477
Name
Fune>fal Director
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�aA �« 0 ° Case#
Date Of Cremati.on NOU it)
zoos
Time Cremation Started / "v() ,Ph
Time Cremation Completed 3- 90
Type of Container
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Remarks
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11/12/2008 15:40 5187477548 M.B. KILMER PAGE 01
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Town of Queensbury
Pim View Cemetery and Crematwlum
21 Quaker Road, Queensbury,New York, 12WX
Cemetery Offlue:(518)745-4476,Crematorium: (518)745.4477
Au#wrizar to Cnmm t6
The undarslpned roquests and suftriass Phe Vlsw Crematorium,in a000rdwoo with end sub)ecx to its Rules and Real*twm to
CorrtlNe the wool,s of:
W.- ,o'm Qr 0`
0119m) (Sao
(street) (city) (state) (ZIP code)
who died an f l_ Z oy FS fty of AIOVey►. Ie 20_a
at
(NOW (Address)
Na�a(r1!(�and addlress d neer�eet tlWrtp relsavo or ry\n►e d person ardrorl�irp asmotlon•
(Aisrns) < (RdOroas)
f�taaonehtp to the \
Name of Funeral Horne
IMPORTANT:
l rapeserrt the t to the Oust d my lvwwtedae,the deceeaeO(has)or(has no)pacemaker,delbMatm or arty ob+er bowery aperaeed
devtoe to hie or her body. (C"One)
I asrlyy that I have to power end auttrora @Wn to WWW for the oxewiWw of the rom afro and to direct the disposirfon of the
cremated nnrirra,OW eery parsorel posaeaelons have etalter been removed or may be destroyed.and agree to protect,defend and
save harmless Plne V%w Crwneo rlum kom arty and all cr kI and demerda*w lose or -1 in, 1 wlid "be merle op li"Ow"
by reason d or oonrte it, %vo the crwemettan d said remains sit dlnxAed,wholwr ouch datms or demands are or are not wholly
(SWAftm
�vid °r L.=Vef�p"esa'antr )
Sipped on this dole: /1�(1(1 %/7 20 y g
D"oeition of cremated Rw mins
I hereby dlrea Poe Vbw OwrAorfum to d'epoee of the- —oddISUCKFUNERAL701MIC.
Wail to __ 7 PARK STRFFT
P.O.BOX 192
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Revislom.January 1,2W6
NOQ-13-2008 14:56 BUCK FUNERAL_ HOME 315 353 2689 P.01 SA
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Town of Quowmbwp
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Coroomy 018m: (516)745-4476,Cremoodum:(51$)745.4477
AuGlorisa6on tD aeWao
Tho w1h end aot"c4 tots Ftl =and FAVAmbiorm 1e
I� eraatMe fbn�irent
I
t tom) t2ta cafe?
j {llddrrir�e?
PAW W oAa ed`dneeo d teiMleR MY�p nNMAr�or tyr�+a of prrstion a +p(�a�oenallon:
Ri
> 1 to tM bw d my l p lc doe,tt+s deowee+a( > S►+rs nv)CecenWW dews"cr any oww bmftj Cjp l I ed
d�PdE er her body. (Ck*Ord
cert�r ►atN1r NtM t7a rnd euranrtotlat emerge for"rsomeft of"*Jul end to I tni'IMF C 11111 F Or the
�nalns.Must 0��ppaliara�ans letie aW�r b0er�ren�oMed ar mty�da�bvled ere to�rout.�,riAMrwi and
srirrr PAte Vww�>roel and tinO d cfdMns etnl deresKpr ttlr laas ords+rl�wr whid► ji Or nMw agaU�p thar►1
ter d ar aonnecMd.Iw+lfta cnraeNon d ftw'soo s a dw'Q n .%fter such Lm a ds+wtnd s aae a sra not«d+oih/
ak
JL er �•,
i
I D"oat m of Co aMd Ro wh a
h� er.tx pm vlarr cr.rnstrrrMrm to dM>aoar at"q I mU MIN Mi �c.
x PORK CTRFFT _-
P.O.BOX 192
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11
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TOTAL P.01