Egan, Gerard (-ro l+N OF QUEEN. B U-�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directory-ems �r
Name G���rpl �� Case # SC)S
Date of Cremation
Time Cremation Started
Time Cremation Completed �j
Type of Container
Remarks :
T co
i
i
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:
(NAME) ` (SEX)
A 53 O I � «c � ' c.�,K e �z er i'1� v
(STREET) J (CITY) (STATE) (ZIP CODE)
,-.,no died on 1A'S day of !y OV e4v,her- 200
at r7j!�A'1S
(PLACE) (ADDRESS)
game afd addressnof nearest living relative or n eLofperson authorizing cremation
r
Relationship to deceased
7
Name of Funeral Home BREWER UNERAL HOME, iNC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has or as n:o:ace aker 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
h claims or demands are or are not wholly groundless, false or fraudulent
n - t , f i(5-ta
I � D s)A i _�h
�� ( IGNATURE O RELA )I R L G R P. AND A ESS)
Signed on this date: cx 4
c