Brodell, Helen rrncnN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 0
Name �� L�" j� gR,0-(� (?'LL Case#
Date Of Cremation Li
Time Cremation Started 44 -5- y i -k'
Time Cremation Completed AA f+ k
Type of Container �4�(z-� �3d� -) Qi/�-►,n�.— Qd��r
Remarks
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518 ) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
(Name) (Sex)
(Street) (City) (State) ( Zip Code)
who died on 133 day of &2�z �3
at.W " d_Lvdurm el
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
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(Name) (Address)
Relationshipto the deceased
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Name of Funeral Home
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IMPORTANT.
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in 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 such claims or demands are or are not wholly
groundless, false or fraudulent. l
P-ate- F /f '&- q
(,Witness ) (Address)
e. A�
(9 ignatT)6f
Relativ or Legal Rep. and Address )
Signed on this date:
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