Cayer, Simon t'
2�"TtiN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &EX— Ap"
Name '5)� X Case # 6 tX
Date of Crematicn
Time Cremation Started
Time Cremation Completed ��"�`�7 9 t
Type of Container
Remarks:
71Y-
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, i
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Simon J. Cayer Male
(Name) __. (Sex)
River Road North Creek New York 12853
(Street ) (City) (State) ( Zip Code )
who died on 21st d a y of December 1998
at Adirondack Tri County Nursinq Home North Creek, New York 12853
(Place) (Address )
Name and address of nearest living relative or name of perscn
authorizing cremation :
Mrs. Sarah Cayer River Road North Creek, New York 12853
(Name ) (Address)
Relationship to the deceased wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased MXXXUX
has no pacemaker in his 4(k XMX 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 eitner
been removed or may be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them r,,.
reason of or connected with the cremation of said remains as
di r hether such claims or demands are or are not wnol : .
�'roundles false or fraudulent .
I
itn—es s > (Address )
(Signature of R 0ative or Legal Rep. and Address)
Signed on this date : December 21, 1998