Gilliess, Howard L. jotul,b v uee2s ur^,
riNE VIEW CEMETERY and CREMATORIUM
QUAKFR ROAD, QUEENS[3URY, NEW YORK 12801
(518) 798.4 726
(518) 793-9777
FUneral Dirictor
I1,111le lJ/�/cy / 13��r�h 1 Case No.
Dale of Cremation
'rime Cremation Started / v` /0 J
'Time Crerrkation ComE>leted , If
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TOWN OF QUEENSBURY 2
PINE VIEW CEMETERY C�
b
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
HOWARD L. GILLIESS MALE
(Name) (Sex)
2025 BAY RD. LAKE LUZERNE , N. Y. 12846'
(Street) (City) (State) (Zip Code)
who died on 7TH day of NOV. 1�9
at GLENS FALLS HOSPITAL GLENS FALLS ,N. Y.
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
LILAH GILLIESS 2026 BAY RD. LAKE LUZERNE, N. Y. 12846
(Name) - (Address)
Relationship to the deceased WIFE
Name of funeral home BREWER FUNERAL HOME, INC.
IMPORTANT:
I represent that to the best of my knowledge,the deceased has or has no 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.
t ss;� (Signature of Relative or Legal Rep.)
P.O. BOX 5 0 2026 BAY RD.
LAKE LUZERNE,N. Y. 12846
LAKE LUZERNE,N. Y. 12846
(Address)
(Address)
Signed on this date 1 1-7-1989