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Cook, Della M- + TO / / OF QUEE9�5BU- V PINE VIEW Y CEMETER AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director <7- GO 0 l-'t, C a s e -cCE 01 Cremation (�,— Ll Cremation Started Q �� Cremation Completed "'De of Container AA �� '-Z'J 24 �E�arks ce el ©v 14,- t . ir•. 'fir �/ 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: T 1 fJ J(J_ C . l oc:�k R ,�s� Name c Sex Street City ate Zip who died on aq day of� �20 at o ym -- aft.t] a 1� place Address Name and address of nearest living relative or name of person authorizing cremation beA Relationship to deceased Y l4sb 1j1 Name of Funeral Home BREWER FUNERAL HOME, INC. IMPORTANT I represent that to the best of my knowledge,the deceased has<as no pacemak in his or her body(CIRCLE ONE) I certify that 1 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 dem nds are or are not wholly groundless,false fraudulent. '_�Z2Z6 IAX'e 46 \� Witness Address C (SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE) signed on this date A4 f Zo�