Meyer, Hugh ' rO gtiN OF QUEEN5BU-I�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorJ3f(�/��Z
N am e �-1 l) �-� n1 �`� �� 1" �-- Case# 2 3 4
Date Of Cremation s - C� _ 200
Time Cremation StartedI
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Time Cremation Completed ,1
Type of Container L' V}��r '�jpyq �'1 ?133
Remarks `J
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TOWN OF QUEENSBURY '03
.' PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 7454477 (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:4(A,Qh A p �h
v F-��e—
ME) (SEX)
T.,nd ian L-aKc- &N is 84a
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 5 day of Mai/ 20_DZ_
at t [ Is .7�f�DI,+a(
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Ed w0-4--d ►�le�,,e.-
Relationship to deceased 'SD n
Name of Funeral Home BREWER FUNERAL HOME, TNC_
IMPORTANT
I represent that to the best of my knowledge, the deceased h or has no pacemake 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
such I s 6r d man or a e of h Ily groundl s, f Ise or fr udulent.
�v
(WTNE S JADDRESS) /
(SIG AIFURE TIVE OR LEGAL REP. AND A DRESS)
Signed on this date-