Mangogna, Caroline M TOWN OF QAJM1J
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director IPYh�t�rT
Name �,a��„� o� Case #
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Date of Cremation J ennv5 II
Time Cremation Started I , N Ph
Time Cremation Completed 3 76A
Type of Container 4,fel uci.c '
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subjecf to its Rules and Regulations to
cremate the remains of:
20L.(r. . MN) OGNA
(Name ) (Sex)
; J _
F cZ L SC 1.-(424CAi AuCz ii•7 . , 4.(J/�,1+)QUv ;' (24- -
(Street ) (City) (State) ( Zip Code )
who died on —7T" day of ^ ,1-9 ZC (v
at trl.ICS711 CiL7(4 CcL,f/' 4) '30 f / 4.
(Place) (Address)
' ! Name and address of nearest living relative or name of oerscn
authorizing cremation :
;
C/ c.i r Aj M !r✓IN6()G v4 62,E ticc mAse-c_F
(Name ) (Address)
Relationship to the deceased //&U
Nam e of Funeral Home A L�)4 ioc-- - if(-7 I (,J4ZC4,SQL426, �.
IMPORTANT:
I -.present that to the best of my knowledge, the deceased has or
as n • pacemaker in his or her body. (Circle One)
I certify that I have the 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
' I and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them b`
reason of or connected with the cremation of said remains as
directed, wh er such claims or demands are or are not wholly
groundles alse or fraudulent .
K
itness ) (Address )
712
��„� 6-+7E 43 .' iic PW'' -
( ignature of Relative or ga Rep. and Address)
1 1
Signed on this date : 7 ' ( (?%--
• I.