Wallace, George zO WN OF QUEEVBU9?rY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director- ✓ 3N -'�6/ am d
Name C�� �� ��1 '� F '�11 �c Case ,1 (J
Date of Cremation �zi — ?-
Time Cremation Started 1
Time Cremation Completed `7 �` ��1 C00t, Q
Type of Container r`{� � �Z (�� l �!' ,�j0 0,4�,,� Li
Remarks :
fZr7_44
11 11 14 3 c-) E
1� ll
TOWN OF GMENSBURY
PINE VYEW. CEMETERY
CREMATORIUM
Quaker Road, Queensbur
Phone (516) Crematorium 745Y4477woroif no rk answerCemetary 745-4476
The undersigned reQuest)sHand ZauthoriD ATION TO R
esPihe EhIAI'EVi •
accordance with and subject to its Rules and R•egulaitionS
cremate the remains of,
Qeorge Wallace Male
(Name)
(Sex)
fir. St. Long Take Ny
(Street) (City) a�8� •
y (State) (Zip Code)
who died on 21 may of February
at Sa a a o
(Place) (Addr�es$)
Name and address of nearest living relative or naigt of pers0 authorizing cremation:
nebarah O'Brien 'P.0. ox 2.76
6"Ne) (Address).
Relatigmship to the deceayed�MIVrF
Nerve of Funeral Home Brewer 'funeral iiome, Inc.
IMPORTANT:
to the best of My knowladger the. deceased has or
hes no pacemaker in his or her body. (Circle One)
I certify that 1 have the for the full Powwr and authorization to arrange
cremation of the remains and to direct the disposition of
the cremated remains, that any personal possessions hay* either
been removed or may be destroyed, and agrov 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 theA by
reason of or connected with the cremation of s4idremains ass
directed, whether such claims or demands are or are not wholly
9r0undl4?ss9 false or fraudulent.
D4borah O ' Brien ox 2
(Witne55) (Address) 47
Jj_
(5i9neture of Reiative or Legal Rep. and Addre W
"i: dato: 2/21/97