Stanley, William rf-M+N OF QUEEN 5BU2�r
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ���(,� ,CE? f�
p�
Name it,tv / ,(9 Case
Date of Cremation
Time Cremation Started ?�ld_ &'Ad
Time Cremation Completed 1e, 45— 191M 1
Type cf Container G�EEo�/9 do" 42-/9n&- d f' zw"f Q�y
Remarks : //
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JIUC-14-2001 02 :59 F'M FORTbNE--KEOi, GH 1 518 8,91 2414 F. 02
TOWN OF WEENSBURY
PINE VIEW CEMETERY
K
CREMATORIUM
Quaker Road, dueensoury, New York 12804
phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned rtqutsts and authorizes Ping View Crematorium, in
accordance with and subject to its Rules and Regulations.:,.to
crenate the remains ofs
William John Stanley Male
(Name) (Sam)
504 Hayeaburg Rd. , Brant Lake, NY 12815
(9trttt ) (City) (State) (Zip Code ) , -
who died on _ _ the 13th day of August
at Home 504 Lrayeaburg Rd. , Brant_Lake, N
_(Place? (Address)
Name and address of nearest living relative or name of p"son
authorizing cremations AvSTIN
Renee Anderson, 2415 12th Ave SW, , MN 55912
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Fortune--Keough Funeral Home Tnc. ,
IMPORTANT/ J;
I represent that to the best of my knowledge, the deceas�ci:
has no pacemaker in his or her body. (Circle One)
1 certify that 1 have the full power end authorization to annange
for the cremation of the remains and to direct the disposition of
the crenated remains, that any personal possessions have sithex
born removed or may be destroyed, and agree to protect, defend
and salve harmless Dine View Crematorium from any and all claims
and demands for lass or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whrthor such claims or demands are or are not wholly
pr le s, a se or fraudulent.
40 Church St. Saranac Lake, NY 12983
tness) (Address)
X40"a., 2415 12th Ave SW Austin, IN 55912
(Signature of Relativr or Legal Rep. and Address)
Signed on this datti August 14, 2001