Keeley, James � .� TOWN OF QU.EENSBURY
Pine View Cemetery and Crematorium
21 Quaker Road, Queenshury, NY. ]2804-5902
(518) 745.4476 (518) 745-4477
hit])//www.queensbury.net
Funeral Director: 0 '0 k-14
Name of Deceased: t 101.A/t,1 e7 6v
Case Number:
Date of Cremation: 1/ / —
Retort: 0- ? I-'U1,
Time Cremation Started: 0
Time Cremation Completed: I 01—Q i4 - L-
Type of Container: 6?-11W4( �(�UJt (�- �}`J 11l4i//' 4 3 v /►��
Remarks:
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• TOWN OF QUEENSBURY ill I
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer) •
Cemetery 745-44,76
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:
JAMES KEELEY Male
(NAME) (SEX)
77 Hulett Rd. Granville NY 12832
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 8th day of November 20x05
77 Hulett Rd. Granville , NY 12832 ,�' 'f •
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at •
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(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation: frix
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t
andra Keeley, 77 Hulett Rd. Granv ,Nle, NY 12832
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Relationship to deceased Wife
Name of Funeral Home Robert M. King., uneral Hometi
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IMPORTANT „4 `
I represent that to the best of my knowledge, th "'deceased has or has no,pacemaker in, is or her •
body. (CIRCLE ONE) rt
I certify that I have the full power and aut `+ ion to arrange for the.cFemat[on of the remains and
to direct the disposition of the cremated remits, that any personal possessions have either bee^
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"frauduient.
P..,,, l d `-.), 1-I;,i4,'t'� "+• 6-C(* yv, tr'�-g I'1/"t ) y '
WITNESS (ADDRESS) ,
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(SIGNATURE OF RELN6IVE OR LEGAL REP. AND ADDRESS)
w Signed on this date: p/ 147 j ) i ,
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