Gates, Robert rl-0 WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name'-^ � 'C �g "����7 Case # 2,
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container 04 (-Odv---t2d 14, I) _lid bff1
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 and Regulations to cremate the remains of:
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Name In Sex
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Street City Ste Zip
who died on e day of 'MIA IIA j 20�
at1��A A9<1'Q,
place I Address
Name and address of nearest living relative or name of person authorizing cremation
Af,±AD b �L� On t'
Relationship to deceased J.t MY�
Name of Funeral Home BREWER FUNERAL HOME, INC.
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 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 such claims or dgmands are are not vvhdly grow Bless,false or fra dulent.
WitneS4Address
(SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date J—3)D y
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