Kathe, David OF
R ROAp MTEEy ANO CREMAT
(518) 74Qgq 6 S9r�Y ORIUM
1`�W YOR}C 12804
,Fame i�v (, Funeral Director �
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Date Of Crema Case . y�i
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Time Cremation
Type of CompleCed
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Town of QueWwbury
Pine View Cemetery and C rOMaknium
21 Quaker Road,Queenabury, New York, 12804
Cemetery Qfflce: (518)745 4476, Cr+t±rrtatodum;(518)745-4477
AuthaxbmdJon to Cremate
The urtdersigno regereate and stollw faes Pk*View cane ndorksm,in ao uft-oe wkh and*Mod to ks RWas and RM tkxm to
txenrete the rememe ot:
'e__ n;�t Le,
/zo J co P- � 2 v
(fired) _ (CM (Stata) (ap Cade)
who riled on jQYIt YL1 - ' 2,W!
(tie} (Address)
Marne and address of nonot living rtrlatfrre or name of posm euthortrirtp owneow;
f_'s,c kc:, wcc'� wiz
(Name) )
Retatl mVV w ttte Baca med—�_CS--%
Name of Frararal Hama 0,4 O
IMPORTANT;
i r vewtt tug to the beat of my kwMedge,the ducoo* d(ttas)orb pe mn*ar,deli or,be fty,batary pads,r
ftw
aaN,rndoeOhe kttplarx or rodboll"davwe W lft cr her body_(ChW One)
i that I twre M power NW wAwriaetlon b arrarpe for#0 OWn&kn of the rem wo to ttNecot the lion of tits
ma creted Tarr akm that any pereorred poeseesioM to"aktter Deer famo rad or maybe des4rvI KL and to protect,do6wi i and
wmhsm*MPMOVI"CmMOWFWmftmOwsWagcWns and dwnwXb lbf bw cr darrmpes with may be wode epnMtet vem
by raeetxt of or cwwwc d wikt the awns n of mM ter mbu as d xiod,whather a ch claims or dery onft area are not wholly
Woundless,him or vc
(Aditss)
and Address of Relat m or Legal Repmerttativ,e)
oiapooklm of Cremated R We
i hereby I c Pine View CrematoAn to dispose,of the cmmated mmek s as*pNows:
Mali 1p
a p/ne kgWn of wameMed remakts is rt d,check here k
Re vi9 w AWN 18,2007