Williams, Mina r `O 7+N OF QUEEN
5B U99 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1y� 1 IV W '1 LLI Case # sS9
Date of Cremation_ - f C 1
Time Cremation Started
Time Cremation Completed (� `,� An
Type of Container c��7 `� �O�` 2 Cam✓
Remarks :
Aj,,�i N
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TOWN OF QUEENSBURY 57
PINE VIEW CEMETERY 5
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 :
Mina Williams Female
(Name) (Sex)
HCR-02 Box 2 Warrensburg New York 12885
(Street) (City) (State) (Zip Code)
who died on the 3rd day of December 19 99
at HCR-02 Box 5 Warrensburg , New YOrk 12885 (Daug . House)
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Edna Blaner HCR-02 BOx 5; Warrensburg , New York 12885
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander Funeral Home
IMPORTANT: q�
I -"resent that to the best of my knowledge, Life deceased �'�{IX9X&f
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 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 them by
reaso AnS .
or connected with the cremation of said remains as
di ectewhether such claims or demands are or are not wholly
g undl false or fraudulent.
Alexander 3809 Main St . , Warrensburg, New York 12885
(Witness ) (Address )
( Signature of Relative or Legal Rep. and Address )
Signed on this date: