Melillo, Antonio L O {''V N OF QUEEN,5BU9Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Ulu f(Z
Name �4.1.*Ic hdl l b Case # 31L
Date of Cremation jig«st 31 ` 2 �
Time Cremation Started t:bV A
Time Cremation Completed
Type of Container �ag4okf l CVAUdOFO � 1
Remarks :
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Audwrization to Cremate
The undersigned rem and authorizes Pine View Crematorium.In accordance with and subject to Its Rules and Regulations to
cremate the remains of
3 l —
(Street) (City) (State) (Zip Code)
who died on day of Z -.0-9
at 3-7 3 ik cdle w L�I I PJ .�
(piece) �j ( )
Name and address of nearest wing relative or name of person authoring cremation:
7R-�-CA0 IV'�e i 11 _3—73 I—� 1�.a �4 Ind
T—(Name) (Address)
Relationship to the deceased
Name of Funeral Home P)M.1 APX fly l
IMPORTANT:
I represent that to the bast of my knowledge.the deceased(has)or �Trie sitar,defibr�ator.battery,battery pack,power
cell,radioactive Implant or radioactive device in his or her body.(Ckcle ) r
cem I certify that I have full power and atahorUntion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium from any and all cairns and demands for loss or damages which may be made against them
by reason
o re re or connected with the cremation of said remains as directed.whether such claims or demands are or a not wholly
J
C I /) 3
(Silymm" /and`dAAddress of Relative or Legal Representative)
Signed on this date 2-
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fol ows:
Mail to
Other arrangerrnenls-Please specify:
If pulverization of cremated remains Is requested,check here X
Revision:April 18,2007