Feathers, Naomi rl-nWN OF QUEEM
,s5B U9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �n�
Name 1` :`7m /' Case #
Date of Cremation`" 02
Time Cremation Started
Time Cremation Completed//����rn�
Type of Container
Remarks :
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08/23/02 FRI 08:13 FAX 1 617 377 4573 IM001
08/21/2002 12:48 518-584-0147 WM. J. BIJRKE SONS PAGE 02
TOWN OF QUEENSBURY "3 1
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road,Queertsbury, New York 12604
P,hbrte(348)Crsmatodurn 745-4477(if no answer)
Cemetery 746-4476
AUTHORIZATION TO CREMATE
The VnftsVnod requests aind authorizes Pine View Crematorium.in ac=dsnce with and subject
to its Rules and Regulatiorw to cremats the remains of:
N(NME) t t
149 Ball8bon AV,e, Ballston S a New
(STREET) (C (VATE) (73P COOS)
.who died on . 9 day of 20-02—
12020
(R A+Cip ODDREW
Naive mW iddress at nearest.ir"relative or name of peroorr a cremadon;
ReloWnahip to
deceased_,_--
Name of Funeral Home
IMPORTANT the deceased�$or p�In his Or her
I represent that to the best My knorried�e
body. (CIRCLE ONE)..
autlwdzg m fo fpr the crernetion of the remains and
I ceRify that I."the fuu pv►Ker e!+d ions have either been
to dirscttha dlspositioil ot`tlre.aBrreated• .that any P '
r� may be'dsatroyed;-end agree to protect'defend and made
6i (from 40 vid�al darns and demands for loss or damsrs
;'against them.by mown of or whrledted with the�d�ters SM e or traWudulenss directed.whether
t.
BUCK ciaims'or deMnds are or are not wh*grau
�Qk Bu adtaaY;' SS, NS
7GN;!AT_UZ RE OF RELAT7,vE�%;zER.ANDAt?OR
Signed on this data: