Hazelwood, Austin TURN OF QUEENSB Uir�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director X/0,UL�rr-
Name Case
Date of Crematicn i s�
Time Cremation Started e'i
Time Cremation Comp1e/ted
Type of Container `i1��fi✓1 /� �°�
Remarks :
1/ I� �FI qLY /O rh
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
a
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:
G. Austin Hazlewood Male
(Name) __. (Sex)
222 Meadowbrook Rd. Apt. Q Queensbury New York 12804
(Street ) (City ) (State) ( Zip Code )
who died on 29th d a y of March 19 99
at Glens Falls Hospital Glens Falls, New York
(Place ) (Address )
Name and address of nearest living relative or name of perscr
authorizing cremation :
Elizabeth Cosentino 22 Logan Ave. Glens Falls, New York 12801
(Name ) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased
has no pacemaker in his UiANX 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 eitner
been removed or may be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all cioms
and demands for loss or damages which may be made against tnem c ,
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wnoi : ,
groundless, f lse or fraudulent .
(Wit ess ) (Address )
(Sign ture of Relative or Legal Rep. and Address)
Signed on this date : March 30, 1999