Fish, John TORN OF ' QUEEV BU-1&y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 's-o �nl I �'1 Case# S a
Date Of Cremation 2-c')C `Z
Time Cremation Started
Time Cremation Completed 1_ '� �U
Type of Container(f.�g,-rxZ -C30t4LZ--J :6AiA ` �0
Remarks
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11 rl
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" 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:� 4�)J'e
(NAME) (S )
(STREET) (CITY) LTE) (ZIP CODE)
f�
vho died on6 day of 20
at - S a-4u CQ dkA-
(PLACE) (ADDRESS)
Name and address of ne rest living relative or name of person authorizing cremation
Relationship to deceased
Name of Funeral Home BREWER FUNERAL HOME, TNC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has or s no pacemaker i his or her
body (CIRCLE CNE)
I certify that I have the full power and authorization to arrange for the cremation of the remains an7
to direct the dispcsition 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 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 clai or dery nds alre qr are no wh I groundless, false or fraudulent.
( ITNESS) (A DRESS)
(SIGNATURE OF R ATIV OR LEGAL REP. AND ADDRESS)
Signed on this date: