Fezette, Lisle Brandon TOWN OF Q. [y/3
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I Funeral Director tin CLARI
Name L /SIe re2etic Case # /00
Date of Cremation rt6 29 Zui0
Time Cremation Started 11" 2 S 191-)
Time Cremation Completed Z lcU pal
Type of Container (Ir(Ltifd triAk) (OJ ) SECOttO Ck1SF
Remarks :
11 ftrk 12'= 30 P t'1 i iof/7
/23o?h
• A"/UCH
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 at
LISLE_ BRANDON FE7ETTE _ �l...LAc,f�/
(Name) (Sex)
992 NYS RT. 3 SARANAC LAKE, NY 12983
(Street) (City) (State) (Zip Code)
who died on 21st dayofFEBRUARY 2016
at RESIDENCE
(Pe) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
MRS, SHIELA BRUSO 180 LONDONDERRY TURNPIKE, AUBURN, NH 03032
(Name) (Address)
Relationship to the deceased SISTER
NameofFunerall-lome M R C'T,ARK. TNC. 23i (l RARAMAr AVP LAKE PLACID, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery peck,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 loss or damages which may be made against 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 or fraudulent.
10 SARANAC AVE. , LAKE PLACID, NY 12946
O
80 .L0ND0NDERRY TPCK. , AUBURN, NH. 13032
(Signet a and of Relative or Lega epresentative)
Signed on this date: FEB. 22, 2010 •
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Maiito M. B. CLARK, INC. .
2310 SARANAC AVE. , LAKE PLACID, NY 12946
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here x x
Revision:April 18,2007