Fleury, Arzella . f
Funeral Director: ID3 CUA��,VC
Name of Deceased:
Case Number:
Date of Cremation: �� J 2 C)C,/
Retort:
Time Cremation Started: i 6 19M
Time Cremation Completed: '!!b
Type of Container:�'�tA��7—rJ t�1 fJ' f 4�� ( 1 U N7
Remarks:
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 145-4476
AUTHORIZATION TO CREMATE
The undersignea eauests and authorizes Pine View Crematorium. in accordance with ano subject
to its Rules ano Regulations to cremate the remains of:
( ME1 (SEX)
--Aga f�a
(STREET) (CITY) (STAY (ZIP CODE)
who died on day of ,Sl [ R - 20 --
(PLACE) (ADDRE S)
Name and address of nearest living relative or name of person authorizing cremalt, n
--I- 1i
Relatinnship to deceased —- --- --
Name of Funeral Home BREWER FUNERAL HONE, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has ;.
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the t~e �e ,.-
to direct the disposition of the cremated remains, that any persona: possess._.rs ri ave e!"-=„
removed or may be destroyed. and agree to protect. defend and save r,ar°mess
Crematorium from any and all claims and demands for loss or da-names = ,'
inst them by re son of or connected with the cremation of saic rerra ns as
suc claims or dem 3rg or are not wholllly�gr ndless, false frar.x9u
(WITNE S) (ADDRESS)
(SIGNAT !RE OF RELATIVE OR LEGAL REP. AND ACE -, s
Signea on this dale: 41`l-�