Saunderson, Wesley TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-44,76
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:
WPc1 Py Qallnrlarapr Male
(NAME) (SEX)
1 South FPdPra1 StraaF , SarAi-nga c rin c, N 122Fh
(STREET) (CITY) (STATET ZIP CODE)
who died on 1 1 day of February 20 02
at Saratoga Hospital_ , 711 Church Street , SS, NY, 12866
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Josslyn Stewart, 6447 NPw St _ , Las Vagas, Nevada, 89110
Relationship to deceased s i s to r
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased inks orn pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the 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, false or fraudulent.
William J. Burke & Sons
628 North grnaciway
(WITNESS) J (ADDRESS) Saratoga Springs,New York 12866C /��
/ 518) 58 =53 (✓ ao
2�( o44'7 2 / te-4 9//6
/SIG ATU- OF RELATIVE OR LEGAL REP. AND ADDRESS)
/Signed on this date: LPb. 12 , 2 n n 2