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Bahlmann, Richard rl-O WN OF QUEENs5BUWY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 , I Funeral Director N a m e 'S�\ G ��� 3 ��-� �,/Y)-A IA\Nk C a se # Date of Cremation 3 `ZC/UILI Time Cremation Started Time Cremation Completed Type of Container (5VJ� 13o is ( ) e6N' y c h—el = Remarks : Pc' - Z 5 COO LL) o n-, 1 D � � a� LIS i 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 undersigned requests and authorizes Pine View Crematorium, in accordance with ano subject to its Rules and Regulations to cremate the remains of: _ t C Cox d to) , I rm o,r) v, Min le- (NAME) (SEX) �� Locker (Zd I nd,a n Lct K-i M`l 14ga (STREET, (CITY) (STATE) (ZIP CODE) ,rho died on 5 day of ov P rr)he*- 200—), t oe ( k( e fed I nd tai', La LAY - (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation 00--d1 _J©hn �on Relationship to deceased irick U c K Name of Funeral Home BREWER FUNERAL HOME, INC. IMPORTANT I represent that tc the best of my knowledge, the deceased ha<:�no pacemaker his or her body (CIRCLE C;NE) 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 fron, 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 94ims or dem rids are o are cot wholly round) ss, fals or fraudulent. , ) i e i(W�I�NE�S") ( R S) (SIGNATURE/JO %ATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: I