Gurney, Cynthia rrn
%_/ (T�N OF
CEMETERY PINE VIER'
ERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director la _
Name - �E1,1' �-
of Case #
Date of Cremation Z
Zr
Time Cremation Started
Time Cremation Completed 2'
SU
1
Type of Container 4(C vA
owir � G
Remarks :
I� 11
L:15 h
Z.5 0
Town of Queensbury
Pine View Cemetery and iufrt
21 Quaker Roack Q Y,New York 12804
Ce"INY Ofiioe:(518)7454476.Cron :(518)745-4477
Abort OD c�rabe
crenate the and ararontaes Pine view q karn,in Womderm v t and subject to Rs Rules and
Female
Cynthia Gurney 1b m to
(Name)
.3A Mo,�,,,�p,, jzr> Hadley
(��) NY 12835
who died on 25th ( )�of July (stata) )
----------------------
at Glens Falls Hospital,Glens Falls, NY 20 09
(Piece) (Address)
Marne andGlenn uaddress of nearest�mW"a name of person mgwru*g aemation:
rney same as above
PlaBborwdptoftdeceesed Husband
Naoraof FurwW Hww Brewer Funeral Home, Inc.
IMPORTANT.
I represent That to the hest of my bwWac pe,the deceased
Oak redom*m inrpiert or redioectt deride in his or her bo*(grdd D)mm giber dew may,bury pads,power
1 oertiy That t haws fiA power and motion to
hermie"OkW. vie ftt w��W p�e�a�e how eaheer been r mnge for the�a�mneks and to dkacx the d on of the
by reason d or MftxWM�°"r and ew damns end demands for lows or be V and��>o Praec4 deferd and
e the cremation of said rerrneirrs as dam,whetlrar such daior VWdd be made ayotrst them
c
denrerxis are or are not w"
5A`IF
(Address)
- u
(sure aro Address of or Lepal Reps)
Sor ed on Ttris date: �0
DbposWm of Cffinatad Rolm
I hereby direct Pine view Q'erttetorhm tD dispose of the awneled mneft as folbws:
w To
O1w anangerneft-Pi=*spedi)r:
V pulvetlz*m of aemetad remakts is requested,drecc here X
Rev+ai=Apri11a 2007
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