Brownelle, Nina OF QUEE9\�5tBUr)�
PLN
E VIES' CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSByrRY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �Name I 1 C-Q
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Dace Of Cremation
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T , me Cremation Started
Time Cremation Complete
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Crematorium: (518) 745-4477 '
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of
N'% a e.� se StN�"r'o
(Name) (Sex)
<< .,z ti�,rks to
(Street)~ (City) J� (State) (zip Code)
who died on day of h1 v C' 5� 20
at G\¢v.S Fes`\5 l�c�� c�c� 10G �cc-� �- �te RAIS tJ�
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Yl�r-L�>wneM S5 -S-,f,CA C-> r, 4'\J +tvr &, e f—c:: t15 N`1
(Name) (Address)
Retabonship to the deceased C�i3 c,�,k-2 r
Name of Funeral Home_1-�- - f �w�is
"IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no) aker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(Cir
I certify that I have 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 claims and demands for ions or damages which may be made aganst 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,felse or fraudulent.
(Signature and Address of Relative or Legal Representative)
i9
Signed on this date: C
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If putvert ration of cremated remains is requested,check here
Revision:April 18,2007