Stoner, John �o%N of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director��c14—MCDAA -Mle
NameA �[ s Case #
K� !T�
Date of Cremation J
f
Time Cremation Started
a /g
r Time Cremation Completed M\
Type of Container clAWRb�j/ D
Remarks : /
fN1 r
r �
/M
3 od
131'/o t4
J
08/19I1999 11.:41 51EI-1745-4474" T D' OUEEh'5EURY PAGE 72
TOM OF QUEENSSURY
RINI VILE K,CIMTMRY
�RZWATORIUM
Quaker Road, Q� eensbury, New York 12904
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-44"0 r
AUTHORX7.ATION. TO CREMATE
The undersigned requests anki authorizes Fine View Crematorium, in
accordance with and subjebt to its Rules and Regulations to
cremate the remains of:
(N ) seat}
Z7- _ - .»
( treeitj ty) (state) (Z P C e
T
s
Rc
who died on ...
at /0 Z'b Z/ZZ,ZZ 94kl�_ 6fQ
(P acey (�ddreas) '
Name and address of neare�t living relative or name of person
authorizing cremation:
651
(Name) Ql ddres s
9;
Relationship to the deceased
Name of runeral Home
IMPORTANT:
I represent that to the beat of *y knowledge, the deceased has or
harp no pacemaker in his or Lher body. (Circle One)
I certify that I have the #ull power and authorization
izationthe t disposition arrange
for the crematSon of the remains and to direct
the cremated remains, that, any personal possessions have either
been removed or may be destfroyed, and agree to protect, defend and
..,.. . save harmless Pine "view Crematorium from any and all claims and
demands for loss or damagios wh4ch may be made against them. by
reason 'of or connected with toe cremation of said remains as
di.reted, ahe such claims or demands are or are not wholly
g ndles or raudulent.
ZZW--/I-
Wk n s — ( ess)
`
gnatu:re of Relative or Legal Rep. an'np dress
gned on this date: �"�.