LaPan, Murriel (7'1-1�+N OF.. QUEEN5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ ELJU
Name Case # qp3
Date of CremationZOOS
Time Cremation Started 1-C)0 Qk
Time Cremation Completed 3"6T p(7
Type of Container
Remarks :
M A TrJ L)k) MOOS
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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
Autlmrization 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:
Murriel LaPan Female
(Name) (SGK)
Luzerne Road Queensbury NY 12804
(Streelt) (may) (State) (ZIP code)
vino died on 10 day of September 20 09
at Luzerne Road,Queensbury, NY
(Place) ( )
Name and address of nearest living relative or nerne of person authorizing cremation:
BeecherLaPan
(Flame) (Address)
Relatiwiship to the deceased son
NameofFurmaltiome Brewer Funeral Home, Inc.
IMPORTANT:
I represern that to the best of my WaMedge,the deceased(has)or ulcer.deiibrilidw battery. pack,power
cell,radioactive implant or radioactive device in his or her body.(Cirde )
I cw*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 loss or damages which may be made against them
by meson of or connected with the cremation of said remains as whether such dalms or dernands are or are not wholly
groundless,false or fraudulent.
(Witness) (Address)
4GY ggat.-
(Signature and Address of Relative or Legal Representative)
Signed on this date: I C'J u 10 U Oct
Disposition of Cremated Remains
I hereby direct Pine View Qenretorinm to dispose d the cremated remains as follows:
Mail to
Other arrangements-Please spm*.
If pulverization of cremated remains Is requested,dreck here X
Revision:April 18,2DO7