Cucciniello, Armand L '
' rO`74N OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Arm&ky� l.v(C I*n (1, Case # 3 �j1
Date of Cremation Lust Zo 20
Time Cremation Started
Time Cremation Completed jU: IV A ti
Type of Container (.,(Cl Lai CEAWFOQU fLQS-r CA.Sf
Remarks :
M A PQ IC) 6N. movi:- I%oa AO)
Town of Queens"
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium.in accordance with and subject to Its Rules and Regulations to
cremate the remains of:
Armand Cucciniello Male
(fie) (SQK)
4 Rockland Avenue Lake George NY 12845
(Street) (City) (Swe) (Zip Code)
who died on 17th day of August 20L 09
at 4 Rockland Ave, Lake George, NY 12845
(Piece) (Address)
Nam and address of nearest living relaWe or name of person authorizing cremation:
Geraldine Cucciniello 4 Rockland Ave, Lake George, NY 12845
(Nam) (Address)
Relationship tot Wife
NameofFuneraiHorne Brewer Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or defiDnfatvor,battery battery pads,power
cell,radioactive knplent or radioactive device in his or her body.(Clyde��ie)
I certify that I have full power and authoriz an 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 CremakAurn from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholly
Wound false or f audulent.
(witness) j; (Address)
u
�
(Signature an Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as bNows:
Mail to
Other arrangernents-Please ape*:
If pulvertzatan of cremateci remains its requested,check here X
Revision.April 18,2D(7