Chandler, James rl-o WN of QUEEM5BUf�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director EW F=
Name_2RA1-� R, CAg )�- Case # HO Q
Date of Cremation — 2 3 Zere) Z
Time Cremation Started
Time Cremation Comoleted � ,� L) �_�
Type of Container�� ���/�,.��� e,zm/1
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
t
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:
Ta rn cs o
(NAME) (SEX)
873 , ever br, l a,Ke Luz -n.,-,- W l �7W
(STREET) (CITY) (STATE) (ZIP CODE)
who died on ' day of � 20 OZ-
at We— kuarjo,C - N Y
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceasedn
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has eii no pacemaker 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 t:e 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 c ims or eman s re a of wholly groundless, false or fraudulent, ,
(WITNE (A DRESS)
(SIGNATURE OFRELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: ! 12Off.