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Monroe, Ann f TOWN OF QUEENSBURY Pine View Cemetery and Crematorium 21 Qunker Road, Queensbury, NY. 12804-5902 (518) 745-4476 (518) 745.4477 http://w%vw.queensbury.net Funeral Director: B Name of Deceased: A N�A /V\/ Case Number: 3,59 Date of Cremation: - - ZG©' Retort: f'�1a '4 tc)4—o i Time Cremation Started: /mil Time Cremation Completed:, -1 � j ��� Type of Container: 6 Iq(ICJ PV-)4 UV/ t.)60 Remarks: nin .5 CD 74 " Honig of Nnturnl Beauty ... A Gnnil Plnie to Live ' 08/03/2005 12:22 518--696--2743 BREWER FUNERAL PAGE 02 Town of Queensbury Pine View Cemetery 8� Crematorium Quaker Road, Queensbury, New York 12KK phone(516)Crematorium 745r4477(if no answer) Cemetery 745-4476. AUTHORIZATION TO CREMATE The undewsirod requests and suttwrim Pine VIM CremsWum,In accordance with and sub)ect to its Rules and Regulations to cxemate the remains of: f t e. M e7Y�OC.� FtYY1t2�2 I "am Sax C && S+- &3do�e& ri,n o s 12 6GO � Sbaet CRY Sme Zip I who died on day of 20 at any r-tto.n 1 Vr7bV j plem Address I Name and address of nearest living relative or name of person sutttaizing cremation I ReletionsNp to deceased r I Name of Funeral Home BREWER FUNERAL HOME, INC. IMPORTANIT I rspresW that to the list of my knowledge,the decesud 1M dw in his or her body(CIRCLE ONES I ow*that I haws M power and authorlsatlon to wymae for the aim-alb of the mmmins end to direct the dspmbm or the cramabd remeirn,that arty personal posseumm hate ebb bean renrored or may be destroyed,end spree to protect,ddtind and ears harmless Pine View Cremda lum from any and d dW=end demands for Im or demm s or darn apse which m:a merle apdnst them w reason or or connected wlh the cremation or said remains as directed,whe"m ad, whamw such clowns or danurds area ere not wooly prwrdlms,false or frauduW4. Witness Address (SIGNATUR OF RELATIVE OR LEGAL REPRESENTITIVE) I signed on this date 31 05 i i I