Parmelee, Anthony L O Y YN OF QUEEVBU9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director a w � R ,
Name p ����� �1�1R n'1 P� Case# 2
Date Of Cremation Q
v
Time Cremation Started `� s b V
Time Cremation Completed b ��
Type of Container not l ���1���-U Ce-)4
Remarks
�to
Coo L -D o u) c� D
2, �� i�
TOWN OF QUEENSBURY 2
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:
A n+honu r L t' (Mate,
(NAME) (SEX)
51 0o l K Ln Quee ✓�sbl r�,f NW Id8ay
(STREET! (CITY) (STATE) (ZIP CODE)
vno oied on 0 day of T)ooe- he.-y' 200,:a_
(PLACE) ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased ni LA
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has or has no pacemaker in his or her
body (CIRCLE ONE)
1 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
,emoved 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
such ims o de ands ar or a e not wholly groundless, f Is
or fraudulent.
dutV
( (A DR S) '
(SIGN RE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: �d`3Oa