Frasier, Dorothy OF QUEEN,5Bu—(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
(( Funeral Director �revar
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T.e Cremation Completed
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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 and Regulations to cremate the remains of:
%JZ�N LiJ
Name Sex
80 kJ hz
Street City a Zip
who died on day of 20�
at
place Address
Name nd address of nearest living relative or name of person authorizing cremation
Relationshi deceased
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased h r has no pacemaker- 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 ma a made against them by reason of or connected with the cremation of said remains as directed,whether ed,
wheteher such claims or demands are or a9D not wholly groundless,false or fraudulent.
Witn Address
(SIG ATU/�RE/�F RELATIVE OR LEGAL REPRESENTITIVE)
signed on this datev V