Pratt, Gilbert TOWN OF QUEENSBURY
Pine View Cemetery and Cremntorium
27 Qunker Road, Qiieenshtiry, NY. 72804.5902
(518) 745-4476 (518) 745.4477
htrp Ilw\v-\v queensbury net
Funeral Director: 3 rPWO r
Name of Deceased: L
Case Number: g
Date of Cremation:
Retort: rg w rc�
Time Cremation Started: 1 cl o A , M -
Time Cremation Completed: I b i 6 A
Type of Container:
Remarks:
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Ho it of N n t u r n I Benitty . . A Cnnif PInte to Ltue
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
Street City J State Zip
who died on_�:7 day of\ , C 20�_
at
place Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased U Lt-6
11
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased has r 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 crenated 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 Ices 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 such�claims or demands are or are of groundless, ^ e or fraudulent.
Witness Address
(SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date___ �/fJ7 &SJ