Bailey, April 7"IIHN Ut" I]IJEENSUURY .' - .-._,....�.,_._ ,�,..a._...... .
NINE VIEW CEMETERY
R
CHEMAfURIUM r
Qualrer• f7c►a�l, laueer►sbur•y, New York 12904
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTI IOR i ZIIT I ON TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains oFi _
(Name) (Se )
(Street ) (City) (State) (Zip Code)
who died on day of 19 _
at �1 ,�y�',��- �r- 1��✓ _--fl__
(Place) (nddr•ess)
Name and address of nearest living relative or name of person
authorizing cremation :
LDA/,�q g919 ILl Y
(Name) (Addroun )
Relationship to the deceased 4 7-
Name of Funeral Home M. B . Kilmer Funeral Home
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 sucli claims or demands are or are not wholly
groundless, false or fraudulent.
N��z
(Hlt.ness (Address)
(Signature of lative or Legal Rep. and Address)
��Signed on this date : /` ��