Millham, Mary nt
roT�N of QUEEN,5BUPy
PINE VIEW CEMETER'� AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director 3rrwor
a�e Icr j�i �� ��•�, C a s e 0,
=a : e Uf Cremation
e Cremation Started hM
" :-e Cremation Completed
;e of Container Cti�c1�o41-V' C114w�vrj 3rc� C''
� :—arks
QM mp 'I ! ' d b 114
i
i
i
i
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:
N Sex
Street City S_Ate Zip
who died on 3 ( day of i.'.[ 20�_
at Ali L4'I) 'iL Q
plar
J Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to aced �1 1 I LAM t!t Ad
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased h or has no pacem r 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 ad,
wheteher such claims or demands are or not wholly GIroundWAs,false or fraudulent
fitness Address
(SIGNATUIRE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date I