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Brockmann, Marion TOWN OF QUEE9 5B2.1_q'' PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 1M G -DC&Mb N�1(SC�kN4 ( Case ate Of 'Cremation Cremation Started ' 0 ' ime Cremation Completed -- - ` pe of Container k AN-Z� W060 prS .4,-141 Re-marks 1 � —01 1 � A/1%, I Jan. 10 2004 5: 36PM Todd StapleyrT^acey Silva 207 -338-0758JIM r 01/10/2034 92:20 15184942948 BARTON MCDERIoCIT Fr#N PAGE 02 f TOWN OF auFENSBURY PINE VIEW CEMETERY CREMATORIUM gu*w Rood,Cueansbwy.New YA 12904 Phor�(61E�CtamaAollum+ T��-MITT(II Ao en�rsr} Cen�nt Tib�Tg i AUTHORIZA11ON To CROWE C �. , wlttt end 80W The ur"v"ned requsgs and Pha Y I to Its Rules OW Regulations to W601 *the ��.. / x i �►�/ .� A (ap *ft died day Of _ao��'*7 C�-I t _T Name and owe"of I"nlative or n*mo of pfw 0*0'Z*V ^ �'AP �t�2.e Z �!r c r 4 Ratstbnehlp to det�►saed hum of Furnerel Home j i IMPORTANT oemelcer in his or her i ngwemd that to the best of W Vwwledgs,the d=*ad or " bo*- (CIRCLE ONE I oerlMp ow I"we the&A popes and aAhMIZOlon 10 lam*ke the a o!the twv*o and I b dMed to dwoom of the tameinc that&V pe>ao W pg hm beW or gy be deebVlWi arb epm io probd,debut and SM t ph*View from Y chin and deml W1 der(M or dwoWs whbb MW be made epmtlnst�e<n tlgF of with ..aw tesdA d,M!!lethW such am (9IR3NATURE OR UaAL REP.AND AD .89D S ped on wK date: `I � f i i i f