Johnson, Benjamin OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director tl . 5. Kilo-or FA
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Date of Cremation% (q-- 0\1
Time Cremation Started 11.' CO A M
Time Cremation Completed
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TOWN OF QUEENSBURY = 5 l
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:
Benjamin Lloyd Johnson Male
(NAME) (SEX)
53 Hudson Street, South Glens Falls, NY 12803
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 3the day of October 20 o4
at Glens Falls Hospital, Glens Falls, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Martha Johnson, 53 Hudson t-rP t-' So- Glens, Fa 1 1 c, Nv 1 ?An3
Relationship to deceased Wife
Name of Funeral Home M.B. Kilmer Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the 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 damages which may be made
against them by reason of or connected with the cremation of said remains as directed, whether
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE F RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: