Braydon, Mary "UN OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director iI <
Name m Aa 1O1ZP,✓2)C N,1 Case #
Date of Cremation J _ 3c., 2G°
Time Cremation Started 1.7 /y\
Time Cremation CompletedQ �^
Type of Container PO,vs O 1'J
Remarks :
(:"Q-,vnttu r-�o (ce) Coe,F-
wG r o ; '�7 to
TM O8 QUaMISSURY
PIMA VIEW CEMEMY
&
C---L TORIUN
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745--4477 or if no answer
Cemetery 745-4476
AUT�ORIZATIOR TO CRMMM
The undersigned requests and authorizes Pine View Crematorium, in:-
accordance with and subject to its Rules and Regulations to cremate-. .
the remains of:
2Zt� I` 1 F�nR-L&r-
( ame) I (sex)
(street) (City) (state) (zip Code)'"
who died on 2 y day of /713 vr+ L -1.g
at w Cs3)/lOti.� l `-kI �8-c t L- T--, r V
(Place) (Address)
Name and address of nearest living relative or name cifrPVO(Od
�J
authorizing cremation: (
(Name) (Address) j; - e7J
Relationship to the deceased �Ydx)6 <6-5-b-�,, � � iW
Name of Funeral Home
LXFORTANT3 J ibbis
I re rev nt that to the best of knowledge, the decg s_ ha ror
as no acema his or her body. (Circle One)' .00
I certify that I have the full power and authori.zitioii to ai=a -go
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 anti..
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 or demands are or are not wholly
groundl s, false or fraudulent
(W to7 D (Ad ess))
(S gnature o Relative o Lal Rep. and ess)
Signed on this date: z