Kellison, Jean rrO q+N OF QUEEVBUj(�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /3� C F=- lZ
Name ]z-L--)- ✓-d Case # S 3 2--
Date of Cremation 1 dl 2��Z
Time Cremation Started r t S—
Time Cremation Completed L4 61
Type of Container 13C)i4, 1�-�✓ `� ti GLASS
Remarks :
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TOWN OF QUEENSBURY Z
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
I
o its Rules and Regulations to cremate the remains of:
a 13 -- �JI I,� Lr �I o"
(NAME) (SEV,
Lake b
(STREET) (CITY) (STATE) (ZIP CODE)
ho died on � day of 9�1Q1/P �'� 20_
at V Y
(PLACE) / (ADDRES
Name and address of nearest living relative or name of person authorizing cremation
Rnxr �) eL
Relationship to deceased
Name of Funeral Home BREWER FUNERAL HomE, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as no pacemaker in his or her
body (CIRCLE UNE)
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 beer
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
again them by reason of onnected with the cremation of said remains as directed, whether
such cla ms or demands a or are not wholly groundless, false or fraudulent
N)o 4qk, C1, 91
(WITNESS) (ADDRESS)
C (SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: It 129102,