JOhnson, John Sr. TURN OF QUEEN4,5BUP..,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
41
Funeral Director ljl-El 16—
Name \1CJA/l ' t/�J/y/V�Cf/1f Case #
Date of Cremation
Time Cremation Started
Time Cremation Completedr ll�
Type of Container G'AM&Aff-L
Remarks :
141 i4i N 90"'G-9
Al
. 3
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 ,
accordance with and subject' to, its Rules and Regulations to
cremate the remains of:
John Kendall Johnson, Sr . Male
(Name) __. . __. (Sex)
9 Henry Street , Warrensburg, New York 12885
(Street ) (City) (State) ( Zip Code )
who died on the 25th day of July 99
19
at his home — 9 Henry Street , Warrensburg, New York
(Place) (Address )
Name and address of nearest living relative or name of pers : 7
authorizing cremation :
Ruth Johnson 9 Henry Street , Warrensburg, NY
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I reoresent that to the best of my knowledge, the deceased has or
as n 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 eitne•-
been removed or may be destroyed, and agree to protect , defer
and save harmless Pine View Crematorium from any and all c ; a : rs
and demands for loss or damages which may be made against them ~ .
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not
groundless, false or fraudulent .
John S . Alexander 3809 Main St . Warrensburg, NY
(Witness ) (Address )
(Signature o Relative or Legal Rep. and Address)
Signed on this date : July 26, 1999