Hutchins, Sherry rro cl4N OF QUEENs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director—
Name-� Hc4& j' �^A Case # W ?>
Date of Cremation
Time Cremation Started 14 —Aq
Time Cremation Completed
Type of Containerj6 �
Remarks :
• Town of Queensbury
Pine View Cemetery
Crematorium
Quaker Road, Queensbury, New York 12804
phone(518) Crematorium 745-4477(if no answer)
Cemetery 745-4476
F,IJTHORIZATION'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 0 Sex
Street I City J State Zip
who died on day of 20 _
at
place Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceasecal Q,v�
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased has has no pacemaker 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,
wheteh s h claims or demands are or are n olly groundless aLse f audulent.
Witness Address
(SIGNATU E F RELATIVE OR LEGAL REPRESENTITIVE)
on this date
ti��