Fitzgerald, Neil I •
•
•
TOWN, OF QUEENs513U1U.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director 7-1N•a 7*.e •A.i 177, L r
Gi '�1pr1r'y Ca s e#
ate Of 'Cremation s - Zoo LA
'• :ne Cremation Started / -� . 15 )2v`'1
'. :me Cremation Completed ? i �' 19 --,--1
"•:.e of ContainerCIA\ V0A-
,vi, 4.t,I tZ :25 121,
Remarks
mQr./di) S-.5- 12"1,,
1 1 5 r7
I33 - 1A
1 �-' 5 t )4i
TOWN OF OUEENSUURY '
PINE VIEW CEMETERY . ,-- • 9 f
a.
CREMATORIUM
Quaker Road. Queerrsbury. New York 121304 .
Phone (510) Crematorium 745-4477 (il no answer)
Cemetery 745-4470
AUTI IORIZATION .10 ClUiMAI E
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its nRu,Des and Regulations to cremate the Iemair 1o1:
rV��1 �/r11i,6 t."/ Z en=r22,ffLb •
(NAME) (SEX)
50z 6%A-r� 2oulE I49 �. 6. IAt 0a.1/5`
(STREET) (CITY) (S•11VTE) (ZIP CODE)
who died on day of C'e-10Urti . 20UL1
at 5O Z Sfrk-i-e- e-4-• )4 i 6/44.2,6; 6t41 j j Z kz-i'--
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
,�t,O IA- r-1-7,.raid 5bz ale, ei , )2R 1 l� (- 0--i.
Y
..,.
Relationship to deceased 1,t� r ce
i Name of Funeral Home CijaZ5Y‘ an(14-Q—
.. Q.l lit.Qh •
IMPORTANT
• I represent that to the best of my knowledge, the deceased has o has II pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for lh ination 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 ba made
agains t em by reason of or connected with the cremation of said remains as directed,whether
su c s or de s are or are t wholly groundless, false or fraudulent.
c
TN ) DDRESS)
NAT OF RE iv OR LEGAL REP. AND ADDRESS)
Signed on this ate: e,2..p6 —O�