Mitchell, Steven rT-o q+N OF QUEENB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEF—NSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorAl4` CLE= /X
Name J '7",5&/-4 M,' TG �i(,JL Case #
Date or Cremation
Time Cremation Started i t-{,�/9 r M I
Time Cremation Completed /Z ifm
Type cf Container G'i91?j9)16A17D / Jr7 , C/
Remarks : GIfV4JF6RD
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08/23/2000 113: 10 518-74 --4474 1 0 _QLE'I'DBUF`; r'r1�t u•:
• ,TOWN OF QUEENSBURY
PINE VIEW CEMETERY
fCRCMATORIUM
Quaker Load, Queensbury, New York 12804
Phone(5181 Crematorium 745-4477 (it no answer)
Cemetery 745-4476
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AUtHORIZATION TO GREMAI C
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The undersigned requests and authorizes Pine View Crematorium, if, accordance wilt)And
subject to its Rules and Rolplation to cremate the remains of.
CJ vea M i&tie It M
(NAME) i (SEX)
Idee, Cam. det, �4�I C f-,W && � A ?,ll
(STREF ) iC% 4`) (CT T;: (ZIP C;Ot)F)
who died on_ _ —. 074? _ I _clay of !r�Aa . 20 p L
at__Ai _kfa N -- l • ---- -- -----_ ---_
(PLACE 1 (A �RESS)
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Nacre and address o`nftarest living relative or name of person eulhorizing cremation;
_ IL4 i
Relationship to deceased,_
Name of Funeral Home
r
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IMPORTANT
1 represent that to the best of my kn wiedge, the deceased h-as or �acemaker in his or tier
body. (GIRCt_E ONE)
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r ertrty that I time the cull power an�authurization to arrange tw the cremation of the remains
and io 6rect t►re 0is.00sitiron of the ci*prr),:,Wd remains, that any tier-one) ,ossessloils have either
beer, removed or r•,av,t-e destroyed.'erd agree to protect,defend and save h3rm1955 Pine Vie`h
Crematorium from any and all clalrn and demands for loss or da rr2;les which maybe made
agains!them by reason or or connected with the cremation of said rerrtains as directed.«t:elt;er
such .-. tms or dwmands are or are riot wholly groundless, false or fr oudulent.
(WITNESS) (AIJURESS)
(SIGN PURE Of RELATI`J: OR LEGAL RF.P. AND ADDRESS)
Signed on this date._
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