Jeckal, Ellie '71/N
F QUEEVBUr�yPINE VIEW CEMET
CEMETERY'
AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name � ( I , ( =g K=(Ml
�t`G t Case #
Date of Cremation l 3
Time Cremation Started
Time Cremation Completed j0- 5'U
Type of Container
Remarks :
g,So
u, �bA�
J
Pine View Cemetery d Crematorium
21 Quaker Road, Queensbury, New York, 128o4
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477
Authorization to Cremate
The undersigned requests and etnFlprj�Pine V'
o remate the remains of View
Crematorium,in accordance_ with and subject to its Rules and Regulations to
(,Nlme�j 4 (.`L I A4
(street)— k if (City)day of v Z kXP
l
who died on t•q (State) Code)
( ) (Address)
Name and address of nearest relative or name
a . .M73A
f'7
L�(, S c`fi 84�
C Cr
( ress)
Relationship to the deceased 5L")to
Name of Funeral Horne /V1
IMPORTANT:
I represew that to the best of m
y kno�
device in his or her body. (Clro1eone) 'the deceased(has) (has no) er,defibrillator or any other battery operated
I certify that 1 have full power and authorization to arts
cremated remains,that any personal pins he eitherfor aem to'Ove of the remains and to direct the save Pine View
Crematorium from io or maybe destroyed,
estro ed and dition of the
by Wesson of or connected with the cremation off and all claims and dernarxh for loss ory agree to protect,defend and
groundless,false or fraudulent. said remains as directed.whether such cat damages 'Ch may
ebe r see against of �
( )
(S and Address ofRelative or Legal Representative)
Signed on thisdate:
Disposition of Cremated Remains
I hereby dWd Pine View Cremalonium to dispose of the cremated remains as fdlorws:
Mai to
Orm+r arrangements-Please specify:
If pukwbsfw of ciao, d remains is requested,check here
Ftrision:January 1,2006