Gilley, John E TOWN OF Q,U✓✓NSBTJ
.R91
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Bawer
Name TUL (j/F, Case # !� �
Date of Cremation Fe 70/0
1
Time Cremation Started l;30 6h
Time Cremation Completed $416fril"1
Type of Container Zrrl boc(rcA CRNIEOF0 f
FiSt Cs4-€
Remarks :
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02/05/2010 17:40 315-472-6215 ALEX M DE CROCE JR PAGE 02/03,
Fob'04 10 10:06a Brewer Miller 518-696.2743 p.3
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Pine View Cannery told Crematorium
21 Maker Rood,Quaensbury,New York, 12804
Cemetery Mice:(518)745-4478,Crematorium:(518)745-4477 •
Authorization 10 Cremate
The undersigned rertaesla and eaMgrti i Pfne Maw Qomelagim.In accordance wen and salloct to as Rums arm RstirYeiaia
airman tree ramie at
ter t L _ �-) yNOW
14 61 tiJ , i h‘rd `'\t _ 2 :)1 ,1 Mt' l 3o(,9
Meal) 0100 (alp Gods)
who died on r 2C1 day otsJeUllAi�
at i ft Z �/�,�. -Th i r cl S L . /1 t 2 Ft/I-}6 r\r t 1371(vri
(Pleas) (Address)
Name end edam,d nearest*Mg Melva ammo d pampa surmising aarnatrors
Me.lissa_ 5r>%zCL
(home) (Address)
Relationship to emsdemoteNevis at Fusel Mons 1`f' 'Ct f Lc • u-y rz,( I��°/7IcyjjlC
(MPORT*Nr:
repraeoml fret so dal bees d my Isscriadois,re decamped(has)or(has no)pecambr.tlaReIlsaor,battery,belay pack paw
peel,regroe vs •�a< his ter her bads
I comfy have paw and a snaige Ibr the alma ifellais and 1D dome the aapoawmt Or the
aamaled r ometa.that cony paraomei pees-salon hers alder bean rammed ter may ba destroys$and ogres to pmolect,dsasnd and
save Itemises Pine ViewCremalakam hoar any and ill chime mid demtads Sr Ices or drertapea tMIldt nosy be mods oPMbt than
by mum dor armac ed rAlh Ole aenledoa ter acid mere as ducted,sdnfror stilt dabs;a drools are or as apt trAloey
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Address of Waal
Signed on Ills doom ( ^2 D/O
Diepossion at Cremated Pamirs
I hereby died Pine View Crematorium to dispose d pie cremated timers ea Islam
Mail to
Other anagomeree•Pees special:M I(CI`x. ' , Ito Y;cz1 ho
t putverl horn at aumaaad remains Is requested,chock here X
Revision:April 1th,2007