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Donahue, Mildred E
TOWN OF. Qf8`Zl PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Weyi.‘ 9,1,1y Name Mi IctMJ 2ucL Case # 10 Date of Cremation Time Cremation Started A�1 �; tit) Time Cremation Completed 17 I Type of Container rz(104,il Cr4w(.r, Flirt � Remarks : M fa CCati coati Io:oofwl 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 r mains of: 11 Irev( chcce_ F. (Name) (Sex) 46/3 '-I--r.t,k o e-46 /rle j1 I e p.,y I Zi'c j (Street) (City) (Stale) (Zip Code) who on £0 day of ,/�.C V1/1 bL_Z- 20 ©C at Acei&f \104e I n r►(ast (Place) (Address)k Name and add of nearest living relative or name of authorizing cremation: 46.114,1 , iQy 136,7(0 (Name) / (Address) Relationship to the d ad 1)A(, kt. V '7 L[, Name of Funeral Home U( (al bee/(1' „la{fa�.Y i fc IMPORTANT: I represent that to the best of my knowledge,the deceased(has) has no cemaker,defibrillator,battery,battery pack,power cell,radioactive Implant or radioactive device in his or her body.( ne) 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 loss 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 not wholly groundless,false or fraudulent. (Witness) I (Address) • 141t-ef --76,-1, , , -,,. .ilee.," 7/,__-ii--,, ,p7.41/„_,,72,7-.. z., ‘76 (Signature and Address ofRelative or Legal Representative) Signed on this date: Ge.„7,f,v_e_tiLy2, , ?0,72 Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: '7-1.-E-12(Ia u %7) 2t A)E--.,1 A.L If pulverization of cremated remains Is requested,check here ' Revision:January 1,2009