Gillies, Richard M I
risOrklAAL OF QLq3 (-.l IC
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director J
Name Z(L,,rd ti (i l ,rs Case # jC)
Date of Cremation Ftbrv4rk) 2 ZcJIO
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Time Cremation Started IDU pr.?
Time Cremation Completed 3 (cTi
Lem/Type of Container 4r-c P,,,,er Rv SICO O CA*
Remarks : Dh
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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:
(Name) a
(Sex)/A2771 /9d/9/V5 Mill6eS /7 - 7W 74/1; Si. 4g12 77/9Aws /49:
(Street) //-- (City) • (State) (Zip Code)
who died on 2 �1`1 4'" day of 20 /a
at /Il A%�/ hld/9/7/5 C&/ CO 61-e_. /7f�,F)7;9" �
(Place) (Address)
Nam and address of nearest living relative or name of person authorizing cremation: /77 Z /L.
') /L . 6;l c/o, V4 ; y /V/ /a,Yz
(Name) (Address)
Relationship to the deceased I,tJ -�--
Name of Funeral Home `���c1 / t�P/2�� e J C
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)• (has no) •-•:maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(CI .: = ':
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 fraudulentA/7
) (Address) �,�/ //� / /�c e.T i /� '
AiU' 2
Signature and A ress of a hive or Legal Representative) I
Signed on this date: / 02 /:,2.0/e2
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: /.1).I) /2/ck cer /�sl -5
t.--/
If pulverization of cremated remains Is requested,check here
Revision:January 1,2009
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4 Igun & Papua ' ixxt.eraI Piontrz
ill rtrt & tt rtnli- nitt2is�Itrt
1lurtrt & ngnnli- �ertri€ettgtt c u g
5 Elm.Street Central Chapel West Chapel
Pittsfield, MA O1201 74 Marshall Street 521 West Main Street
(413) 442-1733 North Adams, Massachusetts 01247
(413) 663-6523
•
Rinaldo l)o!,rn�li l
Edward F. Flynn - 1889-1971 ild Le; Flynn
Edward T. P. Flynn 1928-1985 Donato Pagooli
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DECEACESED: £ ���,P D ' G/ /1/
DATE OF DEATH: _ ,T�/U .—ao�C.)
MEDICAL EXAMINER'S STATEMENT
General Laws Chap. 114, Sec. 4
4
I hereby certify that I have viewed the body of said deceased death and
d ed at am of the~ opinion/� 47`S
/1A
and that I have made personal inquiry into the manner of
no further examination of judicial inquiry concerning the same is necessary.
" Zola-
Witness my hand tilt4 _daY of�L9Nu���' sT
Medical Examiner for the
Uisrict
County of ,e��eLs/// 6—State of — —
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Serving Berkshire County for three generations.