McCane, Nancy OF QUEEN
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 128C4
(518) 745-4-476 (518) 745-4477
, 1 Ci Funeral Director .� �
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N'aTe /VA � Me.c, (�J �. � Case# �--
late Uf Cremation -2-
Cremation Started 8 - �
Tine Cremation Completed
ae of Container� � 'C3a
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lot
01J01i'1999 00: 15 8602821810 C BROWN PAGE 01
05,-27r2003 10: 26 518--696---2743 -9REWER FUCRAL PAM Al
I TOVYN OF OUEENSDVRY
PINE viEvy CEMETERY
� GREMAtCRiU;Vt
Ousker Rosa. OuOeMeDury• NOW yafk 12504
phone,3 t 8) Crematorium 745-4477(Ono of 8WOF I
C* Mtwy I45.4476
AUTHORIZATION TO CREMATE
Tn uraer'ignr+a eauestr end au(norltes Pine view Crarnstorwm In accordance wrth erIC*VD) Ct
,o 4s Rules orlo RM-gul0o"S to Cremote the remWns of:
Raney mccane !caste
t NAML 1 (Sax)
cedar lover Road Tntlan Lau* NT 12842
(s ROE- (CITY) (sTATt=� trP CODE)
ygth BiPtiAbir 2d03
wt{ died on cloy of
et' Cedar River ttaad . Indian LA>re, NY
i (PLACE' (ADDRESS)
NSffm ono address of n9orest lrwng relativo or nernne of person authorizing cremanom
acahall �rorn, 9,5 Ha%thet Lane, Nindaor Locke, CT 06096
R�iatrr mhlo tc deceased e
+m of Funerei dome,_ watt"alk IV*1aAL n0lff. Ice
110PORTANT I teeresont that to the beet of my knowledge,tht deCaased f, Q�h t glQ A or,Ornoker 1h his or tierr
body ,CIRCLE LINE)
rtily that i have the full power end*UftrijaWn to Orton"for the VM0110n of the remains and
t difZt the dispuwtiun of the cremate!!rerl+eMls,tNet eny pent of poesoosions nevi either been
r4moved cr may De tlestroyed emo ogr"to tmotect, dofena and save havMWIll Pine View
�rimetorwrn from Any smd will cloims and derhorift frm loss or dim"eti which nmy to►rode
37ainst them by feasom of or connected with the cremation of saW rerltains a$dirlicm.whathef
eiq claims or dernanas are or are not wholly groundless, f0i$4 or fraudulent
Ai'.V.'A..L40 Sam
r
(Wt NE ) (A E 6)
1
(SIGNA T PE OF RELA OR LEGAL REO XNO A M)
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