Shuman, Charles Sr. rToq+N OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,�� w lZ
ame GNA'44_rS 5+10 0 AN) SK, Caser 32
ate Of Cremation
' ime Cremation Started gyp , Z y4 /'��
Time Cremation Completed
p e o f C o n t a i n e r(!A o
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone (518) Crematorium 745-4477 of 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:
(Name) (Sex)
(Street) (City) (State) (Zip)
who died on 1: (A day of � Cl, 20 'C -A _
at
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address)
Relationship to the deceased At)513pi.(i�
Name of Funeral Home QILi� g
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker 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 against them by reason of or
connected with the cremation of said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) -(A dress)
L
(Signature of Relative or Legal Rep. and Addre s))
Signed on this date: 7/o'�c1�C��
70
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone i518) Crematorium 745-4477 (if no answer)
Cemetery I45-4476
AUTHORIZATION TO CREMATE
The unders)gnec eauests and authorizes Pine View Crematorium. in accordance with ano subject
!o its Rules, anla,Regulations to cremate the remains of:
(NAME) (SEX)
��t ctt W/
(STREET) (CITY) (STATE) (ZIP CODE)
vno vied on 1 day of _ 20 _
at
(PLACE) (AD ESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relat!nnship to deceased G �-L
Name of Funera) dome BREWER FUNERAL TIONE, INC.
IMPORTANT
I represent that tc the best of my knowledge, the deceased has has pac aKer
body (CIRCLE ONE) �''
I certify that I have the full power and authorization to arrange for the cremation ^,:tMe-e•-11- T.r -�,. .
to direct the disposition of the cremated remains, that any personal possessio^s have
removed or may be destroyed. and agree to protect, defend and save harmless F`^e.kVri�r
Crematorium from any and all claims and demands for loss or damages whir" r-a- --,e r-1
against them by reason of or connected with the cremation of said remains as
such laims or demands are-or are not wholly groundless, false or fraudulent.
(WITNESS) -- -- .
(ADDRESS)
(SIGNAT 'RE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this da,_: [421 a,3 � ,