Mahon, Patrick 2"O OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,13/�/-=&,, )�,
K }`�)VR)i19 � Cases (D
Date Uf Cremation
T !me Cremation Started
? ime Cremation Completed l
'vpe of Container—L�t41-Z6 � �
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone c518) Crematorium 745-4477 (if no answers
Cemetery 145-4476
AUTHORIZATION TO CREMATE
The undersignea eauests and authorizes Pine View Crematorium. in accordance with ana subject
to ules ana Regulations to cremate the remains of�
(NAME, (SEX)
�j -- /).
(STRE T: (CITY) (STATE) (ZIP CODE)
vvno died on day of / t'�y►�?°T 20 0)
at oxe— Iak�' r-,,Lk
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation,
Relatinnshin to deceased `>l C r-
Name of Funeral Horne BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has o has no pac aker 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
ala,ms , r dem ds are or are not wholly groundless. false or fraudulent.
NES (ADD S)
(SIGNAT !VE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this da,2