Wood, Ronnie OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funereal Director 4-) 1Z
Name ��lu �( ��, (,��plJ Case# a (o 2
Date Of Cremation It_ Z U
Time Cremation Started
Time Cremation Completed i /�) �s1f
Type of Container /yi4
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 l45-4476
AUTHORIZATION TO CREMATE
The undersrgnec -eauests and authorizes Pine View Crematorium. in accordance with ano subject
to its Rules ano Regulations to cremate the remains of:
(NAME (SEX)
- 0 Id (,-I,J r /YI Yl_)ej- �Llee_y , /J 9,3_��
(STREET'; (CITY) (S ATE) (ZIP CODE)
who died on (�? day of i 200,3
at '
(PLAC& ( DRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relatinnship to deceased 5 �
Name of Funerai Home BREWER FUNERAL HOME, INC.
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IMPORTANT
I represent that to the best of my knowledge, the deceased has r=nTor in his or her
body (CIRCLE ONE) j
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
suc ims o de s ar or not wh Ily r undl ss, false or fraudulen�It.
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(WITN St A DRESS) '
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(SIGN T 'RE OF RELAJIVE OR LEGAL REP. AND ADDRESS)
Signed on this dx!!3(0 �