McDonnell, Paul rr-o%N of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director BCX6(-
Name PW � CQ vnnk �I Case # Zqj
Date of Cremation L (%
Time Cremation Started V40 A
all
Time Cremation Completed 10. (4U
Type of Container n/acClh�Arfi1 I.OW OW f kSj CASE,
Remarks :
�► �� �� s� �n HOLE COON
Cbo�
Town of Queensbury
Pine View Cemetery and Crematorium
71 Quaker Road,Queensbury,New York, 12804
Cemetery office:(518)7454476,Crematorium: (518)745-4477
Authorization to Cremate
The u nders4 ned regnrests and 8udwdms Pine View Crematorium,in accordance with and subject to its Rules and Matt m to
crematexpe remains of
AM
(Name)
(street) �/ (city) �g=�O(Zlpp
7 U'li. day of (. 2t3 0 Q
who died on
i
at
(Place) (Address
Name and address of nearest living relative or name of Person anrttnorb*V Cremation: r �
t Yl c 7
(tee) (Address)
Reiationstdp to the dew
Name of Funeral Home f IQ'�i r`cy'O` �` `►�''
IMPORTANT: the deceased(has)or rto alter.for.battery.f> tom.P�
1 represent Unet ID the best of my btowledAe.
mil,cadioactive;fit or radioactive device In his or her body.
I aerWy that I have fist power and adjWdwhon to anergle for the taemagm of on rem and to direct the dospositiorn of the
cremated remains.that any pemornal vow hevaeow been removed or maybe destmyed and agree to protect,defend and
save harmless Phne View Crematorim trom any and a8rr-;,, and de€aasub for loss ar damages which may be made against them
by reason of or connected with the aemadon of said r es such clialms or dermrnds moor are not wholly
groundless,false or traudulent. �► _ (�d(Addressy. N •!a��J7
-�i� �yr�"r
(Witness) -47 (u )
G
(Signature and Address of Relative or Legal RepresentaUve)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View CremsWum to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specity-
if pulvenzation of cremated remains is regenested,dxxk here
Revision:April 18,2007