Barton, Ralph P[NE ti'TEW QU L
CE r B �-1.
f 4. K?R ROAD,M�TERY AND CREMATORIUM
(518) 745,4476 S6llRY,
NEw FORK 128(N
(S18) 74$.•4477
Funeral Director rIIA
d ' e Of Crematl.on �/ Casey 71 ��(,�/
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Town of Queermbufy
21 Quaker Rm4 Quy, 2804
Cetnewy OMm(518)745-4476.Cm wnaooftw.(518)745-4477
A orizaI. b Cretna�e
Theea uxlembroad
��and ardhoriaes Pies View Qianrow an itlr an
crmft ,in acmdm=wd subject to Rs Rules and Repel woes to
1 .7 h Pmx C lb Mn le-
(Ne e) l-3010
nil lan LQKf- Y 1D42
(streee (CRY) (p bade)
wtw died an I (7 day ofTr j I
at c runL Oct
(Plebs) (Address)
Nerve and aMbaee of trsena I jjvr0 roleliie or creme of POEM arOrortrimp a A an r
2!a fy)f)VA a V-\
(Name) (/�Jdrees)
Fletat;orid tothedeceased I-0 t
Name of FurerBl Ham C-4- r1 k'yyx re ( A-)tm1
IiVKWANr
I t l im m erfI that to the beet of my Ivrowl@dW%the deceased(has)ar pres nr8 Paoeeralrer.delbrilelor.bee".battery Pack Pawar
cak adbeed a trnplsra ar wdioacfiw derloa in Iris ar trer body zt
i certify that i trees fug power end memb adon to amtnpe iar the aarrretion of the rerr a, and to direct the diepoSWon of the
cremated rerrrebrs,teat any parearat poeeeaiorrs here elMrer been rumored c r may be daetroy44 and agree to protect.defend and
save harmless Pbe Wear CO melorlum from any and ag ctairns and dernenrb tar bee cr denrapes which mq be nrede apein 1 them
by ruesom of or oorarScied wllh the rsenreUan of Said remains One dredert.wheNrar such cleirss or dermarrds are or are not wholy
prourdem tabs or*wxkdwrt.
(Somme and Addtees of HaWn or Lao fiepreeo,t dm)
SIM,ved on arts deter � " f )- O �1
ofspasU m of Cmaeted Rovokrs
1 hereby dyed PW View Qamatodum to d kxm of the pemeied reareiat 88 tolbrr C
LWb
ou,erananpemerds-Pbaseseedy: rC I-Cu ,,c Y �' t7,3/1 P rc.i I h0fn1�-�
ff prrlreri m*m of cremated renains to requeeled.check hens 1 --
Reviekmm April 18,2W