Houser, John rrO%N OF QUEEVBWAY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorr�N�
Name 4400 0� Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
^ l
Type of Containe"(qw MA-y �'-d �� /yT
v
Remarks
Feb 19 03 02: 27p MRIL BOXES ETC. #2458 928 772 0500 �-
p. 2
'R M ALEXANDER FUNERA.. HOMO PHONE N0. S1B6232865 Feb. 19 2003 01:40PM P2
TOWN OF.QUEEIVSBURY
PINE VyWfrTERY
CREMATORIUM
Quaker Road,Queensbury•, New York 12804
Phone.(618)Crematorlui:745.4477(ir no answer!
Cemetery•y4$:4�t78
AUTFIORiZATi6N TO,CREMATE
The undersigned regnesai and suihorites P(ne`yiewrCremstorium•in accordanos with and subject
to its Rules and Regulations to cremate the remains of:
John E. Houser Male
(NAME) (SEX)
76 South St., Apt. 2, Glens Falls; NY 12801
(STREET) (CITY?= . (STATE) (ZIP CODE)
who died on
P61i e[ry z0 Q3
his residence . • (sates ea«aboine .
(PLACE) (ADDRESS)
Name and address Of nearest IWIng7*fte Or name of POWn authorizing-wemstion.
Jean A. Houser, 4716'NdF' th Noel ,. Phriae60tt Bailey, Iz. 86314
Mother
ReloWnship to deceased
Name of Funeral Home Ale�tastdsr Fit Inc. Warrensbur NY
RAPORTANT n acemaker in his or her
i represent that to the best of my knowledge,the decaasedtx,ham o P
body. (CIRCLE ONE)
forthe cremation of the remains and
certiy that I have the full pewee,and authorization to:arrange n have-either been
to ctureet the disposition of 'c'`trwlerfxenp �dvatany °.�:�
removed or may be destrajid,,',' tic aEroa'!�'1�rom4ot."batend ar+�slmvs,ttarm s Pine view
cneena from any and all claIR and dernands•fcir loss ordariages which may be made
aipainst them y reason of or eonnec:tad with•Bile rxemati)n Of said remains as directed.whether
such claims dernands are not OW groundless.false or fraudulent
4�1� ,A). A)oe 1 De Al az �c3iy
SS) ESS)
Same as above
(S NATURE F RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this data: 2-19-03