Bressel, Mary t
Z"q+N OF QUEEN5BU,(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
,t Funeral Director (3AKLl2
Name �rr55
Case#
Date Of Cremation� r
Time Cremation Started 35 A�
Time Cremation Completed
Type of Container C1(,jL � K f lFE jrs
Remarks
MArti 1, YL AM
AM
8• ti h� .
� i� A P1
TOWN OF RMNOURI y a
" PINB VISN CZTERY
CREKATORIUI�
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745--4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CXXUAM
The undersigned requests and authorizes Pine View Crematorium in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
2.t3Sb2
(Name) (SOX)
(street) - (City) (state) (Zip Code)
who died on day of /8 eyl �P
I— AorL O ,[ qD,_) [MILS
at I co J y ,�0 4
T-4
(Place) ess)
Name and address of nearest living relative or name of person
authorizing cremation:
1Ia2iC �a (arcl A1Y1?9LL
-� ( ess)
Relationship to the deceased dou�7hkUr' �--
Name of Funeral Home R OL J n O rA 'D"
DORTAXT:
I represent that,to the best of my knowledge, the deceased has or
as no pacemAxOr his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remmaius and to direct the disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, mid agree to protect, defend and
save harmless Pine view Cremmatorium 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
directtm=
d whether such claims or demands are or are not wholly
grounulent. C�AV7=— IT LI No�
11 ��
(A dress)- 1MCI64_1(' 2 /- ?"-k 1 — /
(signature o Relative or ega Rep. and A ess)
O
signed on this date: /O 2