Kenyon, Theodore rro WN OF QUEEN5BUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 'i��'Zv i= '
Name % �C312 � yyt-4 Case # Lk-7
Date of Cremation %L� h� L (��/ L'
Time Cremation Started ! U 14/�
Time Cremation Completed q YA /,—/t
Type of Container ���y7���� �ZiJ 14 3
Remarks :
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Town of Queensbury
J 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:
Tkt1DdDcCerN
Name
K— I __ , , Mal f Sex
��3 < < 12d A+P�n1 kA� lasso
Street City State Zip
who died on day of_0C 20 04
at eQ 0 S
place Address(
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased R
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased hilor has no acemaker 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 as directed,whether ed,
wheteher suc claims or errand aorarenotwhollVgr ndless,false or fraudulent.
x Witness Address
(SIGNATU E Of RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date I D— ( —
0