Sebeck, Joseph . ri-o WN of QUEEN4.,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director x �
Name. -5 y /,l mac- Case #
Date of Cremation ZQG �--
Time Cremation Started 10
Time Cremation Completed
Type of Container
Remarks :
'TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersionea requests and authorizes Pine View Crematorium. in accordance with ana subject
,o is Rules ana Regulations to cremate the remains of:
�Af J.�ep_x Yn 12 L,
(NAM ) (SEX)
cR M_a� Lo � 4L&W_� )I)I
(S EET) (CITY) (STATE) I CODE)
rrno died on n� day of 20
at �x ail , 1Aa,� e
(PL ) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation
Relationshio to ceceased w4lij
Name of Funeral Home BREWER FUNERAL HomE, iNC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has Chaspacemaker i 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
suc I ms or ema ds re or re of wholly groundless, false or fraudulent.
(, /ITNESS) (ADD SS)
(SIGNATURE OF R KLATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:_