Hettema, Susan T074N OF QUEEVBU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/ T//� Jl PL ✓�Q�$
Name � �T.E-� �{Case # �
Date of Cremation
Time Cremation Started
1 A
Time Cremation Completed
Type of Container
Remarks :
Il �l -'t" �n�l
FEB-)2-93 FRI 12:56 U M CENTRAL PURCHASING "-,?J NO. '�'1'�7470733 P. 01
i
TOWN OF OUREMURY
P IM- VIEW CEMTF-Py
CROPprt'OR i UM
Gaaker Road. Queensbury, New York 12604
Phone (518) Cremdtarium 745-4477 or if no an5war
Cemetery '4S- 4476
AUTt DRI ZAT lON rQ CRCMRTL
71,e undersz gmad reg�aeQts and authorizes Pine Uivw Criatiatc u�+, t:
The% aric8. with and subject to tts Ruleo and gcgula� : rzW ""
Acc
r-tamatf. tho �-Qmains oft
5u� Httteme Ferna Ie
-- - -
Mra.
Fg.iZantithtown, N.Y. 12932 __
Park St.
inty) (feat e) (tip Cade)
L2th d aY o f February 19 93
who died or
�,liza})Rrht0wn CAcO fiunity manital, Elizabethtown, N.Y.
=I tpddrrtss)
Name and address of nearest li*Ing relative or namR of Pertsan
autnorlting rreeatio":
Elizabeth-Anne Bracken 49340 fob RAJ. , Ballev�il.le, Mich. �$111 j
(N,sae (Address)
RglatiOnship to the deceased__��,
`�J.M.�rain's Sons Tic. ��r _
Name of Funeral Home
IMMRTANT=
I represent that to the be St of my knowledge' OnQ)deCeased'�hJ
has no pacemaker` in his. Or her Body.
1 certify bn# t 1 haYe the full Power and autharitation to arrallgc
ign Of
for the creMOtion of the remains; �rsesnEldiPaasessiansrect the S have tBither
the cremated regains, that any A protect, defend
been ema vd or way be destecyeds and agree to p
end save harmless Pine view Crematorium from any and all claims
Gt them by
and demands for
connectetior dwithes the icromation ch may be mofQ�sagidinremains as
tAmasdA of or ■andz are or ara not wholly
directed* whether such ullen or de
geoundle*s, false or frauduulent.
Walter S. marvin Jr. F.11zabeLlituwn. N.Y. 12932
(Witnmesl r
49840 Rod Rd. Belleville, �h, 4i311.1
ignatuv- of Relative or Lega! R�tP� m+)d gddress)
2J12193
.. _..�.� nrr this date: