Vaughn, James r
i
OF:, QUEEN
S U-r
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_
Cris rn vr/
Name J� r3 UIU 4{
Case # W7
Date of Cremation
Time Cremation Started
•lb - h
Time Cremation Completed
IV 16
Type of Container 4 j
owtr � 7 i l
Remarks ;
MAr&) g., Zy Ah
'�° $ ( /a�
�ass
JLJN-16-2009 07 :57 PM
P.t
Town of Queensbury
Pine View Cemetery and Crematorium
21 quaker Road,Queensbury, New York, 12804
Cemetery Offloe:(518)7454476,Crematorium,(518)746-4477
5
Authorization to Cremate
The u* req�and suftft"pine View Cmmewlum,in mowd&-Ce wkn end arbJect to i4 Rules and Repu{atbna to
Au eA-
' (Nana) (gam)
cz-t A+)l.. -n e/t/"
Pmw) ram, MY) (State) (Zip Code)
who died on OVY of 20 O`1
at P es, at..« CS4.m �yc
(place) Wldnm)
Neme and address of noomet h*v relatlbe or name of pmopn*WvrIzkV ate,: I /
(Name) U ( ) 1# - ..� .,_... .
RaWkn ttip to the deceesed
Nbrne of Funeral Monty r•_a��•,:+ f t .�
IMPORTANT:
reprasertt that to the beet of my IotowMdpe,the decaaeed(flee)or ra)6Iprfl{etor ar any otnrr pepOrY wed
devla in his or her body. (prde One) �-
I ow*that I have U pourer and&AhortretlM to emerge for the aemedon of ttts remains and to direa d"dMto*Wm of ua
aremtetad renWIM,that arty Persanel poesee810VU have either been rertwvad or may be destroyed,end"tc protect.Mwid and
sm harmless Pins View Cnvr& * n hom any and ell oiainle and demrortdp for bee or dwmig a which may be made apek*them
by meson of or oorneCted wkh tits owwoon d aeid rwna to as dkeded,MOW such claim or denlenda are or are not wholly
t -,A fretJduksnt
(wtrtea)
"'TSiowture end Address of ROWIve or Legal R ( S` •-, a vc
eta epreeenta
r�—a Signed on this date: 0t
DispoalWn of Cremated Remakts
I hereby direst pine View Cnpmetorl=to dispose of tra mmeted reelalna as too":
Mall to
Otfter amertpenterrts•Pbeee epedfy:
If pulv&lndm of ftmated rem im is requested,chsO hers
Revision:January 1,200