Burch, Hollis rl'OWN OF QUEEVBUJZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 141'� lgzy �S- imA-zx
Name d/C !� J' (9 4CCH Case #
Date of Crematicn / / — 1
Time Cremation Started
Time Cremation Completed ^ Til o-w '
Type of
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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 :
Hollis E. Burch Male
(Name) __ (Sex)
8 marion Ave. , Warrensburg, NY 12885
(Street ) (City) (State) ( Zip Code )
who died on 8th day of Nov. 19 98
at Pucker St. , Town of Warrensburg, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Marlene Burch t Zf Z /''�(iU S " RVQVLy G44J s(3v�?�,k/4
(Name) (Address)
Relationship to the deceased Spouse
Nave of Funeral Home Alexander Funeral Home, 3809 Main St. , Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased XrXXXXMd (
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation 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 be made against then by
reason of or connected with the cremation of said remains as
n
h
whether such claims or demands are or are not wholly
Warrensburg, NY
(Witness ) (Address)
yDd"4� /o�' Z�5 -
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 11-9-98