Haynes, Arthur Jr. r'-o WN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 13)q
Name f'� y 1 1X �5 vCase # "Z `-1 0
Date of Cremation
Time Cremation Started
Time Cremation Completed 1
Type of ContainerC,lk\-.0 Y� C) -Pt"V2-� L1
Remarks :
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Sep 16 01 05: 12p Arthur D. Haynes III 518-584-4166 p. 3
10/16/2002 I0:06 518--696--2743 BREWER FUNERAL rt� 03
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TOWN OF QUEENSBURY
I PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury New York 12804
Phone t518) Crematorium 745-4477 (it no answer
Cemetery 745-4476
e
AUTHORIZATION TO CREMATE
The uno�rsjgned requests and authorizes Pine View Crematorium. in accordance with aria sLjbiect
,o is Rules anc Regulations io cremate the remains of:
c
le-
NAME) (SEX)
L � .
STREET- (CITY) (STATE) (ZIP CODE)
who did on -1 q day of re--+p he 78.Ca_
aii �41 a he i#1 rS �61�Q,4 u t 1 )�,c a
j,PLACEI (ADDRESS)
Vane aid address of nearest living relative or name of person authorizing cremation
r�th�r - ��� Jr1 to)aQ nf-�1a.�her rT "Slara+nri0.
N`j I'•%0(0
Re'atiorjship to dF-;eased f)a _
Name I Funerai Nome 9111XV82 POMIRAL KOMI, INC.
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IMPOR ANT
repres nt that to the best of my knowledge, the.decessed ha or has no pacemaker in his or her
body { iRCLE ONE)
certify 1hat I have the full power and sUthorizatlon to arrange for the cremation of the remains and
to direc the dispos,tron of the cremated remains, that any personal possessions have either teen
remove er may oe destroyed, and agree to protect,defend and save harmless Pine View
Cremat Priurn from any and all claims and demands for lose or damages whicfi may oe made
against hern by reason of or connected with the crematlon of said remains as directed, whether
such cl ims or egiwpitq yre or are not wholly groundless. false of frau ulent
s-� (Aj
��T (ADDRESS) G>S
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rr S S Q 5
(SIt,NAT;.irt r
F REI ATIVE OR LEGAL REP, AND ADDRESS)
Signed On this
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