Armbruster, Lester SOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director %33)wr
Name /e,;�6�2 ,4AMNU16f,467gCase # �fZ_
Date of Cremation ]
Time Cremation Started
Time Cremation Completed
-
Type cf Container �(�4�'7�
Remarks :
i
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:
�� Name Sex
`d /
Street City St&e Zip
who died one day of 20 O`
at
place Address
Name and address of nearest living relative or name of person authorizing cremation
AAJl�n ✓
Relationship to deceased, P
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceas has 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 damag4 s or dam-
ages which m;a made against them by reason of or connected with the cremation of said remains directed,whether ed,
wheteher uc laims or d ands or are n whol g ndless,false or f u t
itness Address
( MATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date ��