Winslow, William TOWN OF Q UEENS B UR Y
Pine Vteto Cemetery and Crematorium
21 Qunker Rond, Queenshttry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
httpwwwNy.queensbury.net
Funeral Director: •913 JE W
Name of Deceased:
Case Number: 3 3
Date of Cremation: Z y
Retort: CuA Lt",(fvL2
Time Cremation Started: s�Z 1'M
Time Cremation Completed: 62 �3 A4 X - 4 C)
Type of Container: OA Z� OC ��-J
Remarks:
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" Home of Nnturnl Benny ... A Good Plnce to Live "
' TOWN OF QUEENSBURY 3 ✓ 3
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: ,
MJIL&'� A62)-2'
(NAME) (SEX)
Ma ' n Onr�, in IZ d
(STREET) (CITY) (STATE) (ZIP CODE)
who died on `) day of 1.1 1 20(ML
at NA a-DdL wperA KA,2 nor, - ([<�inn l
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
S fTT 11
Relationship to deceased
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 i his or her
body. (CIRCLE ONE)
I certify that I have the 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 damages which may be made
a . st them by reason of or connected with the cremation of said remains as directed, whether
s ch laims or demands are or are not wholly groundless, false or fraudulent.
L--J`6� C:;4 Chi'Lal) SE , Laki
L
(WITNESS) (ADDRESS)
(SIGN TURE/; " ELATIVE OR LEGAL REP. AND ADDRESS) x
Signed on this dater) 4 ZCO2—