Michaelo, Cappello III 0E- QUEE B`ZZ ,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_
Name IJ4 . C� Io Case # LI
Date of Cremation
Time Cremation Started
Time Cremation Completed Ah
Type of Container GWI"
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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
Authorization to Cremate
The undersigned requests area auttwrtaec Pine View C,remdocium,m acowdsraoe with and subject to its Rules and Reputations to
cremate the remains at:
Michael Cappello III Male
(Name) (Sex)
19 Summit St. , Warrensburg, NY 12885
(Street) (XY) (ate) Rip Code)
who died on 12 t h day of October zu 09
at19 Summit St. , Warrensburg, NY 12885
(Place) (Address)
Name and address of nearest living relative or name of person attnortzung crennanort:
Adorna Cappello, 19 Summit St . , Warrensburg
(Name) (AWr+ess)
Relationship to the deceased M o t h e r
Nameotf-uneraltiome Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the hest of my know4edge,the deceased(has)or(has no)pacesnw*er,deftMatw or any older basmy operated
device in his or her body. (Cirde One)
1 that I have full and authortzebon to arrange fw 00 cremation of the r�eWA**and to direct t the disposition of the
�Pud p �ban bean rerawed or may be d@Waye4 and agree to protect,dWwW and
save Pine V Ciatorium Goat,any and a9 darns and d for noes or damages which may be made them
7
try Igor wRh tlne aernnadort ai saw rerrre tls as dssected,v►kie4►er suds claims or derrrertds are or are not nrrlwYy
g
(witness) (Address)
(Signature asib Address of Relative or Legal Representative)
5,gnec on tnis aate: October 12 , 2009
Disposition of uremated Hematris
I hereby direct Pine View Crematorium to dispose of the cremated remains as tollows:
Mall to
Other arrangements-Please specify:
x
If puNenzation of cremated remains is requested,cheCK nere
Revision:Jygr�,2et7a