Imbrogno, Richard P U`lE Y(E W Qu
CEMETERY A 1. `J
� R ROAD, QIJF?PNS9�YD CREMATORIUM
(518) 745.4476 t�Ew YORK ►z8o4
(518) 745"4.477
Lc'l(c _Funeral Director � 9
\'ame '
h,e ii Case #
Crema io 73
Of tn h
Cremation Started
T . me Cremation ICU �y
Completed ,c; y }
Tr ?e of Container
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Town of Queensbury
pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and a gwrizas Pine View Qwwto lun.in accordance with and subject to its Rules and Regulations to
cremate ttNof:
7/z
(Name) (Sex)
3 c) 2 4
( ) / (City tom)
who died on day of '�l� 20 .07
at c,/�,J3 P. ,
O ( )
Name address of nearest irvMg relative or name of person authortzing creme r /
(Name) (Adder) -- Y/2
Relationship to the deceased )
Name of Funeral Home rU.�S`L d v. 2 Y
IMPORTANT: aicer,detibrf oW.battery,battery peck,power
I represent that to the best d my Ivhowledge,the deceased(has)
cap,radioactive implant or radioactive device M his or her body.
I certify that 1 have full power and authoftstion to arrange for the cremation of the remains and to direct the disposition of the
cremated temakvk that any personal possessions have ell her been ranroved or may be destroyed,and agree to protect,defend and
save harmless Pine View Crarnetoriurn from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the aeration of said reahaW ss directed.wtrel her such cleirrs or demands are or are not wholly
less, or fraudulent.
(Addy
( and Relative or Legal Representartive)
Signed on this date: f��
Disposition of Cremated Remains
ZebyPine View Crematorium to„dispose d the aerated remains as follows:
to O.S� "`-� 1^��"" '
I � Z r u �TO � yl7
Other&Tar ements-Please aww.
if puwertz MW d cremated remains is requested.check here
Revision:April 18,Z*7 l
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