Entenmann, Frances TOWN OF OUEENSDURY q Ce .
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queerhsbury. New York 12004
Phone (510) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION 'I 0 CREMA I E
The undersigned requests and authorizes I-'ine View Crernatununr. in accordance with and subject
to its R nd Regulations to cremate the remains ol:
r,icJC.rs E—Nr�KIJ M Qrnra2.-
(NAME) (SEX)
- --4010Wi" ObrA .FELL, b6t 1v- . la Bo
(STREET) (CITY IS I A I E) (ZIP CODE)
who died on 1 - I day of C--e_L Y Li A2y . 20 0 q
at A 21L Iirsirq 4 n"a
(PLACE) (ADDRESS)
Name and
address
of nearest- living relative or name of person authorizing cremation:
•, r T
N S. 0I ICI 6 (/. .
Relationship to deceased C1 -- '-i 4-ark107_021) 47114-S2--.
''v' ��
4Y1
IName of Funeral Home 1 -Q- - id X�1
IMPORTANT
• I represent that to the best of my knowledge, the deceased has or has no 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 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 ' e cremation of said remains as directed, whether
suc !aims or dernands 'r are n holly groundless, false or fraudulent.
(WITNESS) 4411 (ADDRESS)
> d* Le-1; ...,... i Okt---09—, .
(SIGN,J SRE o -ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: / 1& ZOO