Bissell, Howard OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1 Funeral Director
Name q)-2-!/ ,y/L.St��, �., Z� 6
Case#
Date Of Cremation --L-i
Time Cremation Started b 10 VA M-
Time Cremation Completed 1 , 1 �
Type of Container(? 2C) �k��
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
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AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulationstoo,cremate the remains of:
AME) (SEX)
Lake LazerrY- N lM�f�
(STREE (CITY) _ (STATE) (ZIP CODE)
who died on day ofAnrl20--M
at ` ' /\JY
(PLACE) (A DRESS
Name and address of nearest living relative or name of person authorizing cremation:
?1-n
Relationship to deceased LJI
Name of Funeral Home BREWER FUNERAL HONE, INC.
a
IMPORTANT
I represent that to the best of my knowledge, the deceased has �pacemakerin his or her
body. (CIRCLE ONE)
I certify that I have the full powet and authorization to arrange for the cremation of the remains and
to direct the disposition of'the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect, defend and save harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims dr demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS) +�
' t\ `p \
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dater l U