Cole, Dana TOTAN OF QUEEN B2.1T'y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
yn� Funeral Director
arre •79
Case
ate Of Cremation H
' ir-e Cremation Started
' ime Cremation Completed
of Container
Remarks
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• Town of Queensbury
Pine View Cemetery
Crematorium
Quaker Road, Queensbury, New York 12804
phone(518)Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules ancj,Regulations to cremate the4emaji s of:
(j
Name Sex
Street City State Zip
who died on_ day of 20 (-)4
at An -��..n d CtJq_ L L ,
place Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased La ni&
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased h or has no pacemaker i his or her body(CIRCLE ONE)
I certify that I have 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 damage s or dam-
ages which m:a made against them by reason of or connected with the cremation of said remains as directed,whether ed,
wheteher uch claims or nds r a In wholly groundless,,false or fraudulent.
i
v
Wit Address
(SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date , `