Whipple. Helen ' rOl+N OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I I _Funeral Director �r� (
Name Itip �`� hi Case # 21U
it
Date of Cremation Tune 11 7661
Time Cremation Started 1.0() Ph
Time Cremation Completed
Type of Container �ccl bc7� CC�AuFdRD F-ERST- C8-�F
Remarks :
I Sig, P n Myu-E= z'zWh
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Town of Queensbury
Pine Vaww Cemetery and Crematorium
21 QuOcer Road.Queernbur r,New York, 12MX
Cemetery Office:(518)745-4476.Crema>7oritmw(518)745-4477
Augwrbmdm to Creni to
The wiclw ipted retltreets and auearins Pine view Cr+errmtoriun%in a=Wonce with and subject to Its Rules and Reptrfetiorta to
c t:
e Al -) ; & ����-
(Nente) vv
(Street) (City) ' (SOB) Mp Code)
who ded on 62 cloy of—, TU L) A—, 2D
at-6/ow-5 C A//5 f7 "✓nipl / ��
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Name and adds man d treated w�p reieMve or Wane d peraon aulhorizin0
S�Qa L_
(Mottle) Od/ddrrow)
ReldiaroW to the deceased -�v 9
I�Mrrte d Ftsterd Horne�� r� ��(;a r�1/ /vim�--
IMPORTANT:
I nepteeertt that b the best of ary imowl Kb%the d weaved(has)or pas no)pw .n>dw.ddbiM w.battery,bou"Packower p
COL rad<oecWe t!rr�1 t ar radoadire device in his or her body.(Ctrde One)
I ce W that I hone toil power and wAwrbretiort b w.0 far the amnationt d ttte remelts and b tied the dispoddm of"
creatMind Mawkwo that ary personal posseeefons have eMher been renntored or may be destroyed.and spree to protect,defend and
same harmless Plne view Oremetodum><rorrt any and all datnts and denrerds for loss or dsnrepes wild may be matte apaltat them
by dar eorstsated wM the cremsdort of add ranelts MA i "off whedw aura chins or demands are or one not wtwMy
youndfain-
false ar
rA Po
(smrtatt.e and Address or Uvai Represeraw")
SUnd an this date: G `
DteposWn of Cremated Remains
I hereby tied Pine view the renwh o as tot WM
MeM b
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Other ammvwnw is-Please spew.
If puhrerimtiar of cmvwed remains is requo tad.check here
Revision:April 18,2W7