Pepin, Ronald OF
PwE YrEv�r QU 9\�5B
EM�TtRy AND
CREMATORIUM
UCPR ROAD, QVEENS9URY UM
(Sl8) 74S•4�76 NEW YORK 12804
(S18) 745.•4477
s Funeral Director1 ,
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02/23/2909 12:34 5187477548 M.B. KILMER �PiQ 03
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (618)745-4476, Crematorium: (518) 745-4477
Authorizedon to Cremate
The undersigned requests and su tortzes Pine View Crematorium,in accordance with and subject to its pules and Regulations to
cremate the remains of:
h1C,VA
(Name) (Sax)
f P ��ns Ny ) �goo
( ) (City) (3tate) Ip Cade)
who wed on k r\„A rx v /Z- day
o'�f'- `,—re Gl, u 20 C)9
et_ C t' r(A- _l��_- 17 r�•.`1 _�! , �� F?Y ,r� f �� tv(�/ 1
(Piece) (Address) 1 1 O o
Name and address of neareet living relove;[orr name of WSW etrthorbft pen Slim:
l�
(Name) (Address) ,
Relationship to the decebsed nil S� / - 1 n - I G W
Name of Funeral Home V),)e>r
IMPORTANT:
1 rep wmtt that to the beat of my Io70wVladga,the dedeeeed(hat)or(has no)pacemaker,datibrillator,bettery,betbary peck,power
cell,radioactive Implant or radioactive device in his or her body.(Circle One)
I Car*that 1 have full power and authorization to mange for the cremation of the remains and to direct the disposition of the
cremated remains,thin any I po ions have eBher been removed or may be deotroyed,and agree to protect,defend and
save harmless Phe View from any end all delta and demands for loss Or damages which may be made eDahst them
by rmswyQf or the adon of said remains as directed,whether such claims or demands are or a/re wholly
ground
' (131pnetare rass of Relative or Lags ean epratative)
N y If
signed on this data:
Dispoaltlan of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fellows:
Mall to
Other arrangements-Please spsdty:
If pulverization of cremated remains Is requested,check here
Revision,January 1,2000