Danielson, Carl C:) __A TOWN OF QUEENSBURY
Pine Virtu Cemetery and Cremn tort 11M
21 Quaker Rond, Queensbury, NY. 7 2804-5 902
IIJW (518) 745.4476 (518) 745.4477
http//www.queensbury net
Funeral Director: Z-
Name of Deceased: t✓1412A., PP-1 i e: 'LSO I�
Case Number:
Date of Cremation:
Retort: r=
Time Cremation Started:
Time Cremation Completed: C�
Type of Container:
Remarks:
' '10
" Nome of Nnturnl Benuty ... A Good Ploce to Live "
07/0 7/2005 14:39 518--696---2743 BREWER FUNERAL 61 1-11
TOWN OF qU&EN58URY
PINE VIEW CCMETERY
3
CREMATORIUM
Quaker Road.Queenoury. New York 12$44
Phone t518) Cremstorl►.Im 5-4477(if no answer)
Cemetery 14
AUTHORIZATION TO CREMATE
The undersigned reaueSts and authorizes Pine View Crematorium- in accordance with and subject
to its ales aria Regulations to cremate the remains of:
t�E
(NAIA] I
tTL— IUM a
(STREET. (CITY)
(STATE) (ZIP C )
20
40
who died on
day of
at
(PLACE) (Ajl!�u DDRESS)
Nafm and address of nearest living relative or name Of person authorizing cremation:
6� athens;hip to decea A 9
d
Name of Funeral Home
�"
I&WORTANT acennaker in his or her
I
I represent that to the best of my kn mthe deceased o
body, (CIRCLE ONE)
I Certify that t have the full power and authorization to arrange for the Cremation of the remains and
to direct the disposition of the cremarted remains.that any perso ml 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 sold retneins as directed, Whether
such claims or demands are or are not whotly groundless, false or fraudulent.
TM SS A DRESS) '
( AT,IRE OF LA IVE,'Q&LEGAL REP, AND ADDRESS}
Signed on this date: —7 S
_. . .� "f Tssn "W',TnaW COAT AO1 TPQ 4V4 IA:AT Q1)n7:Ln:"Ln