Sanderson, Wesley T- o OF QUEEM
,55B U9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (J/tK
Name ldi�J� �/4/1��i���O/� Case # ~f
Date of Cremation
Time Cremation Started 10., c;z9 f 1M
Time Cremation Completed tz ! 0 p/m
Type of Container_ ����J1�
Remarks : � �'
Feb 13 02 05: 2Sp RL MASSEY 2018690866 p. 2
02/13/2002 15:51 518-5e4-0147 WM. J. BURKE & SONS PAGE 4?
TCWN OF QUEENSSURY
PINE VIEW CEMETERY
& i
CREMATOR1t:M
QUaKer Road,Queensbury, New York 12804
Phone(515)Crematorium 745-4477(if no answer.)
Cemetery 745.44.76
.. i
AUTHOR;ZATION TO CREMATE
The unaersigned requests and authort4es Pine View Cremaioriurn. in accordance with and subject
to its Rules and Reguiadcns to cremate the remains of:
AQ
i
(NAME) (Sex)
jSTREEf) U (CITY) (STATE) (ZIP CODE)
who died or _, day of
at ���l'fl C dtr
(PLACE) (R DRESSI
Name and address of nearest living relative or name of person authorizes cremation;,
4- 06� OL
116
Relationship to dec7ipsed
Name of Funeral Horne
IMPORTANT '
i represent that to the best of my knowledge,the deceased hagcemakar in his or her
body. (CIRCLE ONE)
I certify that I have the fuft power and authortMon to arrange for the cremation,of the remains and
to direct the disposition of the cremated remaisrs,that any perscnat possessions have either been
removed or may be destroyed,ar:d agree to protect.defend and save harmiess Pine Ww
Crematorium from any and all claims.and demands for Ions or damages which may be made
against them by reason of or connected with the asmation of sold remains as directed,whether
such claims or demands are or are not wholly groundless,false or fraudulent.
William J. Burke & Snna L�
(WITNESS) (A NESS) 8 N Br iid
ItAt
'Or'�"Yt 4 1 1 r (l0
t ATUR QF RE VE OR LEGAL REP.ANG'ADDRESS)