Jacobsen, Jancie LOr
Town of Queensbury
Certification of Cremation
7 Pine View Cemetery and Crematory
This certifies that the remains of: Joseph Church
were cremated on September 23 20 23 at the Pine View
(Month) (Day)
Crematorium, Queensbury,New York, and these are the cremated remains of said body.
Date of Death September 19 20 23 Age 35
(Month) (Day)
Funeral Home Regan,Denny,Stafford Funeral Home Registered No. 763
(Autho tzed Signature)
JACOBSEN
Owner
Ken & Jancie Jacobsen
Address Plot
5 Pines MHP, Ft. Edward, NY 12828 Cayuga #1
Phone # Lot #
518-769-0754 g-24
Deed # Date
4414 10. 17.23
Cost Foundation Y - N
$800.00
Location West-Vacant
South-Vacant
East-Vacant
North-Path
Remarks
I ACKNOWLEDGE THE RECEI OF THE RULES AND REGULATIONS OF THE
PINE VIEW CEMETERY:
SIGNATUR : DATE: D 2'3
SIGNATURE: DATE: i o i 7 ) ag
I
Record of Intermen s
1 6
4 9
5 10
J(1Cn i
••\)
I - der, A
EDL a _ 2-0
a -,S05-0-44\ q iq
iLJ �
n v
T
JACOBSEN (LF�
1
NAME Jancie Jacobsen Age: 79
Lot Owner: Ken & Jancie Jacobsen
Lot# Cayuga #1 g-24 Grave# 2
Case: Urn
Died: 4 .9.2 4 Interred: 4 . 1 6.2 4
Funeral Home: Regan Denny Stafford
Cemetery: Pine View