Nichols, Pauline TOWN OF QUEENSBURY
Pule View Cemetery niid Cremntonum
27 Qunker Road, Queenshury, NY. 7 2804-5 902
(518) 745.4476 (518) 745-4477
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Funeral Director: ?'f'�f w -.--/,
Name of Deceased: 1'cLu 1`h2 teos"
Case Number: 3^(S
Date of Cremation:
Retort: 7*1 L.c
Time Cremation Started: Lie, W,
Time Cremation Completed: i I P^
Type of Container: ar-jLo0L'rj
Remarks:
MAvej ` ` 3 0 14
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" Home of Nnturnl Beauty ... A Cool Plnie to Live
Town of Queensbury
Pine View Cemetery
8�
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 crematep the remains of:
Name Sex
71 (n -H d l ✓ t X 12832
Street` City State Zip
who died on 2/ day of V (y 20 0,5—
at G ) irs1L
place IfAddress
Name and address of nearest living relative or name of person authorizing cremation
Lhv is o S kt kit-kols
Relationship to deceased C h) 'd cl!q
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased h5l has no pacemaker i 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 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 ed,
wh er uch claim or demands are or are not wholly groundless,false or fraudulent.
the ddress
v (SI NATU E OF R LAT OR LEGAL EPRESEN IT E)
signed on this date