Harrington, Lloyd Qu
AND
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' R ROAp CREMATORIUM
QIJ ZNS9URY, NEW YORK 12804(518) 745.4476 (518) 74$'•4.477
Funeral Directorc�
Cases+
Crematl.on
1
Te � remation Started r7, .2,
: remation Completed -- 16
P1
%e c ! Container
Town of Queerisbury
Pine View Cemetery anti Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery office:(518)745-4476,Crematorium: (518)745-4477
Authorization tD Cremate
The undersigned requeats and authorizes Pine View Crsm®torium.in accordance with and subject to its Rules and ReWWatiorw to
cremate the remehe of
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( (Sao`)
7,20 lqt-SAN y ST Ho c? .N j/ /230 °7
(Street) (CRY) ( ) Vp Gode)
who died on _,_..f
dWd
at F</� 5�/TAB Sc61fn/���ADy Al`/
Name and address of nearest Wing ekctive or name of pmew authoriatng cremellam
�cJ �A22iNG�-� SCf/�Pfl S-T L-AS-11-�,E'.u-/
(Noma)
Relationship to the deceased r'VFPf1f i.r✓�
Name of Funeral dome SgrW t IZ F-..�✓�QgL
of ray
I rep" AIYT: the deceased(has)or(Tres no)pecennalrer.deiinrillelor,battery,battery tom.p
ower
1 ropnessrk t hat b the best Isnrywiedga.
oak radioactive mqmt or radioactive dodos in his or her body.(finds one)
iti
t carWy Wet I have# paw and nd po tsfon to tM eo m been renrw�ed nodon or n my dedrayed,end agree to pcnlectoderernd and
sove tm remains.that array personal posseeeionw
save tmrrnlssa Pine View(:nerrretoriun from any and all cJatns and dernerds for toes or dernoges which maybe made-air-them
by reason of or n P.-ed wih the cxen orlon of said nemakw as dbeclsd.whslhar such ciefnas or dernnards are arms nwt wlwly
Mae o
(Address)
( and Address of Relative or Legal RepresWftdva)
Signed on this dale:
Dippooldon of Cmwvftd Remains
I hereby drat,Pine View Q W natorium to depoeq of d*Olmsted remain as follows:
Mato
Odw arrerngenne"-Please Spew.
If &Otmdm of crem9W rerr*kw is mWeded,check two
Revision:Jarnary 1,2WO