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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name /7/Y�� /C/J/j � Case # rl(P2
Date of Cremation v0�
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Time Cremation Started/ C�— � / I �
Time Cremation Completedczts"5
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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, .
accordance with and subject" to its Rules and Regulations tc
cremate the remains of :
Andrew Blaner Male
(Name) __. . __. (Sex)
106 Horicon Avenue Warrensburg New York 12885
(Street ) (City) (State) ( Zip Code )
who died on 24th day of April 1999
at Glens Falls Hospital Glens Falls, New Ynrk 19SUl
(Place) (Address )
Name and address of nearest living relative or name of perscr
authorizing cremation :
Mrs. Edna Blaner 106 Horicon Avenue Warrensburg New York 1288
(Name ) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased3093DOM
has no pacemaker in his 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 , defenc
and save harmless Pine View Crematorium from any and all clams
and demands for loss or damages which may be made against them ^ ,
r-e- of or connected with the cremation of said remains as
( direct d whether such claims or demands are or are not wnol : 1
ground ss, false or fraudulent .
_ 5
(Witness ) (Address)
(Signature of Relative or Legal Rep. and Address)
Signed on this date :--,April 24, 1999