King, Vivian r-r
L O O
p F QUEEN,5oUTCEM `J
K.ER ROAD, TERY AND CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745.4.476 (518) 745.-4.477
Funeral Director
Fame �/' NIILLf
t�
Case#, �3
Dante Of Cremation Z ,(G � of
time Cremation Started
7:• S 0
Time Cremation Complete
1: -6
Type of Container (n/ _
Art ✓U4r j ph.cr' T
Remarks G
M = S OC) r.
�Qo� ISO Ah
Town of Queansbury
Pine View Cemetery and thorium
21 Quaker Road,Queensbury, New York, 12WX
Cemetery Office:(518)745.4476,Crematorium: (518)745-4477
Audwizakm to Creme
The undersigned requeste and aulhoriaes Pine View CnImBlorlun,in accordance wNh and subject to Its Rubs and Regulations to
cremate the remains d:
Vi van K 1nn mcdc'
(Name) i
(Sent)
(A' AADcAL - IQ
Meet) (Cky) (Soft) (Zm Code)
who died
\\on 1<k day d �c C _y2D�'
at ��r►lrz�a lia r K �)r L l l\� h� �i O i�� h L�t'�' I- ,
(Place) ( )
Name and addres's of nearest pving relative or rrerrne d person auanorLft cremation:
(Name) (ems)
Relations*to the deceased
Name d Funerd Flomne
IMPORTANT:
I represent that to the best of my Ivwwledg%the deceased(hers) pecsmnalcar,detbillalnr.betlery.batlery Peck power
cep,radioeclive implant or nmamcdw device in Ms or her body. )
I certify that I hew foil power and a*wrbiadon to arrange for the aernam, d 1M remains and lo diked the deposition d the
cremated re resins,that any Personal possessions have 9Wwr bssn rerrwvad or may be destroyed.and apres lo prolect,defend and
arm harmless Pine View Crwmloriun from any and all claims and demands for ion or damages wMch may be made against them
4reason d a connecied with the cremeUon of Said remain as directed.wheUner audn clairrns or demands are or are not wholly
false or fibudntlert.
,.,.}}__�- (Address)
(Sipnatnxe and Address of Rela ve or UQW Represertetiw)
Sipped on this data:AL.&JI
Dispoeltion of Quymftd Remains
I hereby direct Pine View Qemelalum to Sep ose of thre crarrtded remehm as 1010wa:
Map to
Other arrange rnents-Please specify K 1�QSe In I iazy&( I UJm)—e
if puhrerizdion of crerneted remains is requested,cfneck here )C
Rwisbn:April 18.2W?