DeGroat, Robert 70` 4N OF QUEEVBUP.,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �o h rT fA/f -N- �-roa�-r— Case# -S9
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container CA41'-d 1�U►dl�Ld
Remarks
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TOWN OF QUEENSBURY
t
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 and subject
to its ules and Regulations to cre to the remains of.
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(NAME) (SEX)
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(STREET, (CITY) (STATE) ( IP CODE)
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wno died on day of 20 dog
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home BREWER FUNERAL HONE, INC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has o =no
n 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
wl�iQ-J
ds are or ar not olly groundless, false or fraudulent.
(WITNESS) ((ADDRESS)
(SIGNATURE 16F RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: ( 07