Bronk, William a
rl-ng+N OF Q�iEEVB 21�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name _�� !Ij LIi lti'i ! & IC Case %'J
Date of Cremation , 4 �5 — �\�
Time Cremation Started
Time Cremation Completed/,-' ` �� /� ' Al a
�l
Type of Container
Remarks :
i
3054568794
03/26/91 21:24 3054568794 JIM CANAVAN PAGE 01
,...
02/.22.e99 04:27 CARL.E"TON FUNERAL HOME 1 19544568794 NO.501 p��2
T N OF 0Uj1 ik=UPY
Ii E VIEW CBM RY
a
CREMATORIUM
Quaker Flood, uesensbtla , New York 128Q4
Phone (K 18) Cre torlum 7410-4477 or If no answer
metery 74.a-4476
AU RIZATION TO C"FIVIATg `
The un4arsignesd requests and thorlass pine Vlsew , re►natorlum, in 40egrdanoe with
and ss►ubloot to Its Hulas and ft gletlone to oren+a a *ho remains of:
WSW" M, oreffias >r�e
(Notnse) -
as7 a�srl �. 1i Pa1.3a, � #use
(Street) ."-
I t) I ICItY! (State) (Z)p Code) -------T
who died on day of 99
at $7 8 OVI $treat t 1HU440sk F41
Place) 11 (Addro4s)
Norris tend address of nearest li no relotivh or hemp of poreort a Uthorlaing aromationsr;
t sr►ms) j lAe�dre�a�s!
(Relationship to the deceased SOW
Name of Funeral Home 4W Mal .
r
IMPORTANT!
1 reprasomt that to the best of knowiedga, the deceased has or as no
paszerr+akar in hi# or her body. ircle Ono&
1 certify that 1 have the full pea and asluthorizatipri to arrange for the ore"otion
of thg rornslns and to direct the lspoeltion of the cremotad rom einst, thet ony
persronal sesosalons have elth We" rernoved or may he desrtroveEd, oncl asirs+e '
to pro .. . afend and save her loan Ririe View Crsernotorlum !rpm an and all
claims and emends for tons or "urges whloh May be made ainst them
by n all oonnected with 9 orerrre of said remainsd)reoled.
the such clsAims or demand are not wholly groumdlsAs4al;, falter or frasudulaent.
s! tAddreare!
(Signature of Relative ! Legal Rep. and Address)
I`
Signed on this dater: ., ..,
f
it •