Brown, William TOWN OF QUEENSBURY
Pine View Cemetery and Cremntortum
21 Qunker Road, Queenshnry, NY. 12804.5902
(518) 745-4476 (518) 745.4477
http /lw\v\v queensbury net
Funeral Director: t CIA na,r fi �� r
Name of Deceased:
Case Number:
Date of Cremation:
Retort: - .
Time Cremation Started: 12 - 3 y
Time Cremation Completed:
Type of Container: Ci'�a l I;>kf L�- CyN
Remarks:
P 1q m ti-j-e I i 3 U PM
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co-it CIUw L �.. �T
Ho ne of Nntttrnl Benut A Coed Plnie to Live
TONN OF QUSXll-SSIIAY
4
Pills VIXK C8MET =0
CR8lIATORIUM
er Road, Queenebury, New York 12804
Phoneg(318) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUT�pRIZAXXOo To CRSIG=
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who. died on ,� . 1 g 2 b o day of
at �1QP a► 1'-cej 1a Ml� ,n �� - 0ite M ftN4\;A [�u �2kQN
Address) t
Name and address of nearest living relative or name of person
authorizing cremation: r p
(Name) (Address)
Relationship to the deceased
Name of Funeral Noma ,�.��(1C1u; Q l�l P,� �'I,() .%A-
IMPORTANT:
I represent that to the best of my knowledge, the deceased' hasor
ha�` jn�;pacemaker in his or her body. (Circle one)
I certify that I have the full power 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 clai 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
groundless, false or fraudulent.
(Witness) '- (Address) �—
(Signature 'of Relative or 'Legal Rep. and dress)
Signed on this date: � •e i 9 -c-) S—