Kellison, Cathrine OF. QUEEN5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�� �.
Name_ �pr,,-„ I1IIli*- Case # Z
Date of Cremation 0 Zo
CA
Time Cremation Started q' pO
Time Cremation Completed
Type of Container v %� Q
Remarks ;
MAT fih MODE- � ' 1 U a4
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Town of Queensbury
Pine Yew 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 authorkes Pine View Crematorium,in accordar"with and subject to its Rules and Regulations to
cremate the remains of:
_ 6AT-flj?J"1F gF-;Awo/`/ F
G 1 )2.s7)1 S% 1 571 C NY, 'vL/ 09m)
is vo,-A/ti,,a vrF- ,.w r3g - zldke—L.1�4 � NY
(street) (CRY) (slue) (zip
who died on 2/✓D day of SEA 20_!gS
(Piece) O
Nam and address of nearest living relative or name of person aWhorizirg cremation:
(Name) rJ ( )
Relaboriship to the deceased ! ► `-S131►�✓A
Name of Funeral Home 139L�tz r,)VG Hn
IMrepreserrt that to the best of my lurowiedpe,the deceased(has)or aker,defibritistor,battery.bettery peck.power
cell.radioactive implant or radioactive device in his or her body.(Circe )
1 certify that 1 have Tull power and authorization 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 protest,defend and
save harmless Pere View Cramewrirao from arty and all claims end demands for loss or damages which may be made against them
by reason of or connected with the of said remains as directed,whether such claims or demands are or are not wholly
groundless;false trakduierrt� � ��
�f (Address)
( of Reistive or Legal RepneserdaWe)
Signed on this date
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows
Mau to
Other arrangerrrerrts-Please specify:
if pkdverization of cremated remains is requested,dm&here X
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Revislon:April 18,2W
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