Hovey, Goldie t -
rrnWN OF QUEENs5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 'j ''i)
Name tIVI, 4J
Case; C111,5'
Date Of Cremation 11) — _
-- o -
Time Cremation Started_
Time Cremation Completed
Type of Container��i Y �'�'► rlt4�Z� o A./A
Remarks
• TOWN OF QUEENSBURY
PINE VIEW CEMETERY o
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 145-4476
AUTHORIZATION TO CREMATE
7e signed -eauests and authorizes Pine View Crematorium. in accordance with ana subject
+.'!es and Regulations to cremate the remains of:
(NAME) (SEX)
(STREET., (CITY) STATE) ZIP CODE)
.vho died on Q day of U 200,1
at
(PL CE) (ADDRESS)
Name and address of nearest livin relative or name of person authorizing cremation:
Relatinnship to deceased / t2�� --
Name of Funerai Home BREWER FUNERAL HONE. INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has �asnoacemaker 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
laims or dem nds are or are not wholly groundless, false or fraudulent.
02
(WI SS) (ADDRESS) '
�((SIGNAT 'RE/O-FI�LAT�IVOR LEGAL REP. AND ADDRESS)
Signed on this