Cadbury, Warder �O,+N QUEEVBURY
PINE VIEW U_:`1ETERY AND CREMATORIUM
QUAKER ROB. -, QUEENSBURY, NEW YORK 12804
(518' -4 5-4476 (518) 745-4477
1 F r ral Director �`j/�/=Pt/ f �Z
Name�j l�-U � � �� (� Lq
c>12 Case # �J ��
Date of Cremation _ �f — L9, "3 t-,
Time Cremation Started_ 25 r7
Time Cremation Comple ,L
Type of Containerj{p�
Remarks : \7
MoAd
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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:
I
Name Sex
Eoa5+ 6101( V, 10, n kaKL / Ida yc�
Street City State Zip
who died on I day of 20.8
at 25 Fo,4 Mm n 5 t I nit o q La k_,z_
place Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased l) (
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceas h 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 demands are or are not wholly groundless,false or fraudulent.
Witness Address
(SIGNATURE RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date