Barry, Kathie L TOTIN OF Qiy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /1L CLJ f
Name 41e 3c (fl/ Case # 3
Date of Cremation J 4nut,,r`y 1 ZUtel
Time Cremation Started 1 !U An
Time Cremation Completed q- hp PIM
Type of Container ( (46q+rc1 vw?; Rsr J1 � r5t as(
Remarks :
31 (WI
_i
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:
KATHIE L. BARRY FEMALE
(Name) (Sea)
•
2 RT,TZARF.TH AVF._ APT 5 MASSF.NA, NY 1 '3552
(Street) (City) (State) (Zip Code)
who died on 30th day of DECEMBER 20 09
at MASSENA MEMORIAL HOSP MASSENA, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
SHANNON ROWE 562 SPRINGFIELD RD. ,WILMINGTON, NY 12997
(Name) (Address)
Relationship to the deceased DAUGHTER
Name of Funeral Home M R C T.A R K, INC- LAKE P T.A C T D, N Y
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle 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 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 *or fraudulent
R. -e( --/( 2310 SARANAC AVE. LAKE PLACID, NY 12946
(Witness) (Address)
X1erm�, --cam (2 L 12-1 7 ��o 562 SPRINGFIELD RD. WILMINGTON, N`
(Signature and Address of Relative or Legal Representative)
Signed on this date: DEC, 31 , 2 00 9
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
Other arrangements-Please specify:PICK UP BY FUN'L DIRECTOR
If pulverization of cremated remains is requested,check here XX
Revision:January 1,2009