Wisell, Daniel (7'4OwN OF QUEEN ��
s 9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ BREW c '771-"
Name Lll� ►V L �` �j �a.� L 7.. Case;
Date Of Cremation Q_ 1 b 2C-10�
Time Cremation Started
Time Cremation Completed 1
Type of Container014
Remarks
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
4 &
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rule d Regulations to cre ate the re ains of:
KAO-A,d
AA
(NAM (SE )
)v
(STREET) � j (CITY) _ (STAY (ZIP CODE)
who died on day of 2003
at
(PLACE) ( DRE S)
Na an address of nearest living relative or name of person authorizing cremation:
i�
Relationship to deceased
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased haCr�hasno aker in is 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 cl mms 0r mangis are or e n t holly groundless, false or fraudulent.
(WIT14ESS
(SIGNATURE OF R IVE OR LEGAL REP. AND ADDRESS)
Signed on this date: (P
t'