LeFebvre, Celia OF QUEEVBU-9�
PINE VIEW CEMETERY AND CREMATORIUM`
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 51� ffori
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Name L L� iG Ze I eLyc-t Case # L
Date of Cremation PCc''nbt,r li 7W
Time Cremation Started
Time Cremation Completed f0 , 151) l
Type of Container _ �r��our 0 r, �
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Remarks :
9-,211-A
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 and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
C t,IA LOPE L3V2E �E1mA1.�
(Name) (Sex)
AyjAmcaA QUCE
(Street) (C fate) (Zip Code)
who died on day of Z0�
at<40_AQATI0a R0. . 1A F9:SBuILO .�D W I c-13-0�
(Place) (Address)
Name and address of nearest living relative or name person ac oriz7ng crema�ori:— -- — — — --
i c p� t=-EE, 13 V R t 5�D A v IA-no ,1 R0..Q 1A EEKSf�U r J\ . I a�C r}�
(Name) (Address)
Relationship to the deceased jS o�, A
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) er,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Ci One
I certify that I have full 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 protect,defend and
save harmless Pine View Crematorium from any and all claims and demands for k)ss 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 riot wholly
groundless,false or fraudulent.
- t (Address)
fia AVlA71oN
(Signature and Addreek 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 follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here J4� —
Revision:January 1,2009