Van Allen, L. Ernest �O O .
P LN E YT E PS' QUEE9�oUrK_T
CEMETERY AND
f�(4' KER ROAD, QUJEF BURY CREMATORIUM
(518) 745.4-476 W YORK 12804
(518) 745'.4.477
game I Funera Director >
'Fwr�
Of Cremation r
t D
me Cremation 66
Started
Tame Cremation COmPleted
Tree of Container
I Sf S
,. °vM � •y s �,y
y • Z
Town of Queenskw"
Pima Visw Cemetery and Cnrrtetorium
21 Quaker Road.Quee Wk".New York. 128"
Cemetery Offkw.(518)745-4476.Cmrok ri m-.(518)745-4477
Autltorizoliori tD Cnwnate
The c.dwsipned requests and suftobw Phw View denWa4unk in e000rdsrroe with and=*4sd to he Rules and PAPAAtlons to
cremais the renraits c t:
(Nears) (sue
1'15- #144,19 P9 GA&;f A-.�,.E A/Y IZr6
(street) (CRY) (SIM00) (ap coat)
who died an 6 71# doy of )CSE821-- 4gY 20�
at �L,�vs F�GLs NosPr/� �r'�F_i✓.s Fs��cs Ny
(Piece) Uddress)
Name and address of rrsareet iivft feieWs or named Psi arettormrp aemaeon:
,H ti n V.I., '7 AYMAI7 ?D�, L� �c.zF�z✓E N y
Oddrow)
Rststiwshipiothedecsased �'✓�
NomedFurrerdFforrta � °-✓Ee �'-"✓�/�� �'`�
IMPORTANT:
I represent that 0 the best d ON IalowMt4s.the deeeeaed(tree)or peconnirer.dalbrisror.beaery.bWwy Patric.Power
cei.radioscgM irtpiarr-or radi c 11 -dwloe In his or her body. )
1 cw*that I hams fui power and s*wdnAM ID anenpe forties oenta d' d the renrairrs and to dtiect ties depositlon d the
cremated rentabrs.that erw pwsad pogeesbrrs tress aiher been removed or may bo dselrvyad.and apes w protect.defend and
save harmless Pure vier r um i from any eed eft tishns od demands for loss or damages whidt melt be made epaked them
by reason a carrrsdsd wih the ^stiart�d(sdd rem�alns as direcisd.wtwgw suds ddia\tsI or dwnsbs are or as net wlw�Y
pro s a
(Wllrrses) (Address)
QE2qvU -
(Siprrourre and Adtfrese ofRelative a l opal RepresertmUve)
SWrted on this dote: ~�' C Gj
oteposow of Crannied Rename
1 hereby tied Pine Vises C:nM aiorAtm to dtapoae dgte gaaaled renrelns as foiortrx
Mai b
Other arrangwroo s-Please seedy:
If p4iorbstim of cramsled terrains is requested.check here
Revision:Apra 18.2W7