Brown 11, Ricahrd E Tod of QfB'uj
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name RAJ-re/I Brot.)A y Case # 33
Date of Cremation Ti-elol 7( 1 7010
Time Cremation Started
Time Cremation Completed 1< <IS ;; rj‘ -1211
Type of Container tArc(boc,/c1 f ow° Thi
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 acahodzec Pine View Crematorium,in aoc oe wish and subject to its Rules and cremate the remains ot: Regulations to
Richard E. Brown II Male
(Name) (Sec)
1075 Vanpatten Rd. , Duanesburg, NY 12056
(Street) (City) (State) (Zip Code)
who died on 17th day of January zu 10
at Ellis Hospital , Schenectady, NY
(P ) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Rirhar-I Brown 1075 VanPatten Rd. , Duanesburg , NY
(Name) (A )
Relationship to the deceased Father
Name or f-uneral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have ated remains,%t and authorization to arrange the cremation of the rem and to direct the disposition of the
any personal p have utter been removed or may be destroyed,and agree to protect.defend and
save haarless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or gdnnected with the cremafficn of said remains as dratted,whether such deltas or demands are or are not wholly
9roundiess,lee or fraudulent
fitness) G 7(j l?L .
A d ei s ,�
1L' )
' S 1E, A
(Signature and Address of Relative or Legal Representative)
signed on tnis sate: January 20, 2010
Disposition or cremated Remains
I hereby direct Pine View Crematorium to disprvgg.of the cremated remains as fotiows:
Mall nO
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remains is requested,cheat hers X
Revision:JjJ -3O04
i����M 07