Ball, Mary TOWN OF QUEENSBURY
Pine Virtu Cemetery and Creinntoriiim
21 Quaker Rond, Qiieensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
hire //www.queensbury net
Funeral Director: l3 0- G ��Z--
Name of Deceased: PA
Case Number: I4
Date of Cremation:
Retort: T FP—
Time
Cremation Started:
Time Cremation Completed:
Type of Container: t',yV\Za ti3d4,II7,1,) A44) 0 D L
Remarks:
24014
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" Home o/ NntlirnI Benuty ... A Good PInce to Live "
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 r�te the remains of:
NaSex
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street City state zip
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who died on day of C_t 1 t 20
at `► ►�
place Address
Name and address of nearest living relative or name of person authorizing cremation
��';VC� � �' ► f'1 Cie
Relationship to deceased lv �.C
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the hest of my knowledge,the deceased has or has no pacemaker in his or her body(CIRCLE ONE)
I certify that I have full power and authorization to arrange for the cremation of the remains arw 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 ad,
wheteher'f uch claims or demands are or notpholly groundless false or fraudulent )
Witness Address
.. L
J (SI NXrURE RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date