Burgess, Robert (-rn7+N of QUEENSBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director '= kJ F_ +k—:z,_
Name /:9)C> f3ER Case# 2 Le Zf
DaJte Of Cremation
Time Cremation Started
Time Cremation Completed
Type of ContainerGy.,,:�'Ibvv4i�X,3 _ 1Adadl
Remarks
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TOWN OF QUEENS13URY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answers
Cemetery 14b-4476
AUTHORIZATION TO CREMATE
The undersignec eauests and authorizes Pine View Crematorium. in accordance with ana subject
to its Rules ana Regulations to cremate the remains of-.
Hale—
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(NAME, (SEX)
I� 2e-ricns
(STREET'; (CITY) J (STATE) (ZIP CODE)
Nho died or, day of J'1 r to 20 Q3
at Git tt i 4G� G 1 --
(PLACE) (ADD ESS)
Name and address of nearest living relative or name of person authorizing cremation
zle—
Relatinnship to deceased
Name of Funerai Nome BRxwER FUNERAL T10HE, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased ha or has no pacemaker �is 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
Crematorum 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
s clams r e nd are or are not wholly groundless. false or fraudulent.
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(SIGNAT 'RE Of RELATIVE OR LEGAL REP. AND ADDRESS)
Signea on this da:3: