Keefer, Guy Jr. L O O
PWE 4Y QUEE9\�5oUrp
YIE
CEMI1 TERy AND CREMAT
I7UXKER ROAD, QV"' .
�'NSgURY ORTUM
(S 18) 745.4g76 THEW YORK 1280a
(S 18) 745.4.477
Name
Funeral Director
f/
Case, ��C1
Oate Of Cremati.on
Time Cremation
Started
T 1 m e Cremation Completed
R 10 ,
Type of Container /� r
Remarks
tl
"00 L
Town of Queensbury
Pirie View Cemetery and Crematorium
21 Quaker Road,Queensbury.New York, 12804
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Audi zation to Cremate
The tudarsipned requests and authorizes Pkre View Cremator um.in accordance wtih and subject to ire Was and ReguMm to
c remsde the re M*W of:
�uU �, P ��7r• Ma��.
�3 C)M, ion rru �a�e. OU-011 .bu U 12-YL'K
( ) (Cky) s"i"—cam Cam)
who died on q— day of ele Mn2
at �1 ��� � r����( P��SY ��IPMc �'►aI( (1. 1� �
lf
Nome and addrees of nearest living relative or name of person eLtwrtzhg cremation:
Md u gort Is u,'2' l�(•
O '' ,, 1 ( ( ) l
ReireimuMp to the deoeeeed W;
Name of Furw*►come MOUIV e_-
tlN nWAW:
i repraserd that to the best of my b Mdedg%the deceased(has) ( )peoerrrdllaer, alor or any other befty opented
device in his or her body. (Chute One)
1 cartity the 1 have tug power and authorization to arrange tot the cremation of the remalns and to direct the disposition of the
O nreted rarrrdM that any perearam poeseaslom trays either been removed or maybe destroyed,and agree to pr-Olect,defend and
save harmless Pine View CremsWASM ban any and aM ciaNns and derrrards for loos or derrre9 which may to rrrade against own
by reason of or wMr the/awneft of said ran i* se dlrecled,whether such chains a demands are or are not wholly
' I ) Z,4.4
�s
(somwe end/Addrow of Relative or Legal Reves )
Signed on this dale: ` N e
Disposition of Cremated Remains
I hereby direct Pine View Orerrrato um to dispose of the aemaded remains as follows:
Mall to
Other anargernanla-Please s peW.
N puhwbstion of cremated renuft is requested.cinch here
Revision:Jarnrary 1,2WO