Flanders, Van OF QUEEVBU-Ry
PINE VIEW CEMETERY AIND CREMATORIUM
QUAKER ROAD, QUEENSBURY, ;N,*EW YORK 12804
(518) 745-4476 (518) 745-4477
"�
Funeral Director �(,pK�
Name /y lj Case # 3
Date of Cremation A2 A:d -
Time Cremation Started b 1(�� f�
Time Cremation Completed 151jt<0c5 A -M
Type of Container [;/9&J)5:�AfD `5
Remarks : l
t l
12f07J2001 10:07 0023345435 MULKIN CORP FI OFFIC PAGE 01
12iB7/2001 08,26 518-594-8147 WM. J. BLPKE & SONS PAGE 01
•'i
TOWN OF QUEENSSUP,Y
PINE VIEW CEMETERY
CREMATORIUM
& Z,3V
•
Quaker Road. Queentlbury, New York 12004
Phone(516)CrenlatorNm 745-4477(if no answer)
Cemetery 745-447e
AUTHORIZATION TO CREMATE
The undersigned rests and authorzes Pine View Cremrrtoriurn, in accordance with and suoject
to its Rules and Regulations to cremate the r+mains of.
(NAME)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 6 day of camber 204.1—..
at 297 50u" Qr n 'ptd nidi Gray f o jt r.�:nC�ii "w`� 334
(PLACE) (ADORES$)
Name and address of nearest living relative or name of person authorizing crem Wn.
1 C1ind�v t�,)�y /YGdr� VeC�ont _�!
R"tonship to deceased Son
Name of Funeral Home William J. Burke & Sons Fungal Jimma
NAPORTANT
I rapresent that to the best of my knowiedge,the deceased bU pgs 0p pacemaker his or her
body, (CIRCLE ONE)
oetilfy that I have the full povrer end authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any pW$"poss"stom have eitMr been
removed cr may be destroyed,and Agree to protect,WwO and sew hexmtass Pine View
Crematorium from any and all claims and demands for loss or damem whlCM may be made
against them by reason of or connected with the cremation of said re`�dlr'�UAc�" a
sueh c*ms or demands are or are not wholly gmundleas,false or fro North SroadwaY
�. � Saratoga springs,Now York 13110
(ADDRESS) _
(8IONA'TU LATIv LEGAL REP.AND ADDRESS) l
Signed on this date: