Gaurino, John (r0 WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /✓ j„ I-Z,,-
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Date Of Cremation C)G
Time Cremation Started 16 -, 25
Time Cremation Completed
Type of ContainerLbAl- 0 13014(2--t)
Remarks
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TOWN OF QUEENSBURY
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 accorcance with and subject
to its Rules and Regulations to cremate the remains of:
C194,x- a
(NAME) (SEX)
5 /O) &L
(STREET) (CITY) _ (STATE) -Q (ZI ODE)
who died on /e day of 2063
at
(PLACE) (ADDRESS)
Nam and address of nearest living relative or name of person authorizing cremation:
t2n� Aa
Relationship to deceased
Name of Funeral Home BREWER FUNERAL ROME, TNC
IMPORTANT
I represent that to the best of my knowledge, the deceased has has no acemaker 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
inst them by reason of or connected with the cremation of said remains as directed, whether
uc claims demands are or are not wholly groundless, false or fraudulent.
9M
(WITNE S) (ADDRESS)
(SIGNATURf4Or RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: V62