Bunt, Judith 4
TO"M/Q OF" QUEEN5BU-rQy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
Funeral Director.
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BREWER FUNERAL HOME, INC.
MICHAEL J. MILLER
P. O. BOX 500, 24 CHURCH STREET
LAKE LUZERNE, NEW YORK 12846
5 1 8 6 9 6-2 7 4 4
Body D� elivery Receipt
(Required by Section 4145 — NYS Public Health Law)
A. NAME OF DECEASED PERSON:
(as it appears on burial,cremation or transit permit)
B. DATE THAT BODY WAS DELIVERED: l ='
C. NAME AND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAKING DELIVERY:
(Print Name) (Reg. #)
D. NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral'Firm Name)
E. NAME OF OWNER,OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSITION WHO RECEIVED THE BODY:
(Print Name)
CHECK(✓) IF NO ONE IN CHARGE
F. NAME/LOCATION OF PLACE OF FINAL DISPOSITION:
(Name) _ (City, State)
7:
(SIGNATURE of FuneralDirector) (SIGNATURE of Person Receiving Body)
White Copy--Funeral Director Yellow Copy—Place of Final Disposition Pink Copy—Decedent's Family
' TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone t518) Crematorium 745-4477 (if no answers
Cemetery 145-4476
AUTHORIZATION TO CREMATE
The undersigned eauests and authorizes Pine View Crematorium. in accordance with ano sublet;
to its Rules ano Regulations to cremate the remains of:
{NAME! (SEX)
iz 6 -- ) J� -4.2 S
(STREET: (CITY) (STATE) (ZIP CODE)
.vno died on day of d4&2 2063
at 2::Al� 4
,15`LACEI (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relatinnship to deceased
Name of Funeral Home BREWER FUNERAL HOME, INC-
IMPORTANT
I represent that to the best of my knowledge, the deceased has has no pacemakerA 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 connecteil with the cremation of said remains as directed, whether
suc ci ins or ma s e or ar no oily groundless, false or fraudulent.
Ir
(WIT SS (ADDRE S)
,SIGNAT 'RE OFF R LATIVE OR LEGAL REP. AND ADDRESS)
31
Signed on this day C