Monda-Stimpson, Gina Marie TOEN OF QAjB
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorBA Z.
Name M0„d4 - 5 I ,., huh Case # 13
Date of Cremation re �j 12 r 7010
Time Cremation Started S ; D7 417
Time Cremation Completed 10110 ill
Type of Container (-rAaa,r01 /uwer- 0(1(
Remarks :
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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:
Jr; Aic ti fl ri ei t"J0KC.19—�'`I r►p soi/
(Name) (Sex)
7 w l I,Jul- s T - ttuis i%19 ils , At,Y, 12 83
(Street) (Ci fy) ) (Zip Code)
who died on /() day of l e w >1 zo a
at G.lef.JS rAil04o& iTIO- (leLISF19II5/X' , 128'.1>!
(Place) (Address)
Name and address of nearest living relative or name of person authorizing err ation:
NMI 0-i irot4X f 9 W eJeA/ UriU.e -V4edeas b uYy,A1 ,122/ay
(Name) (Address)
Relationship to the deceased S i zl e y
Name of Funeral Home til aviNo vd p,tog e v-
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,false udulenL
O (Address)
(Signature and Address of R ' or Legal Representative)
Signed on this date: ! e p•j D'? f1 I o
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
Revision:January 1,2009