Bucklin, Rodney SOWN OF QUEEVBU9 y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name )- 6O k)�L( P Case# 1
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container C,� \' 4D 30 4 V�j
Remarks
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
s
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:
e-&CJs)t,\1 P.
(NAME) (SEX)
t UL0 rt4tJC-,r- Glens lls 1\�� I ? go
(STREET) (CITY) (STATE) (ZIP CODE)
who died on y day of Lax'( 2003
at C1 "mrlu Q
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
-2nL9- l:�t A C k l ►n
Relationship to deceased dow A V\-I-r-r
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has Cras o pacemaker 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
e%ueftc aims r de nds are or are not wholly groundless, false or fraudulent.
L&
(WIT S) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: I03
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