Brown, Juanita SOWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 5iri(,,fPCyl ��ealy
Name Jy4n t � Zrown Case # -a/
Date of Cremation -?- la- pc q
Time Cremation Started � q0 ► m
Time Cremation Completed 1.0- is :
Type of Container Cari baaj yVu4'n 0 1 4k'P7
Remarks :
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TOWN 01: QUEE14SUUIIY
PINE VIEW CEMETERY 3a
CREMATORIUM
Quaker Road, taueensbuiy. New York 121JU4
Phone t510) Crertnatusiunr 745-4477 (it no answer)
Cemetery 745-4476
AUTI-10RIZA' ION I U GREMA I L=
The undersigned requests and aulhwizes Dine View t,iematuimm. in accurdance with and subject
to its Rules and Regulations to cremate.the remains ul.
(NAME) (SL=X)
moo" br ,. Y1 l g
(STREET) (CI"IY) (S I'AI (ZIP CODE)
Q
who died on 1 clay of _ 20-0-4
at
(PLACE) (ADDRES )
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or as 11v acemaker 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 aliy 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 crelrlatlon of said remains as directed,whether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: