Adams, Mary TOWN OF Q UEENS B UR Y
Pine View Cemetery nnrl Crematorium
21 Quaker Road, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http://wNvvv.queensbury.net
Funeral Director:
Name of Deceased: y-z� u � ►�l�l
Case Number:
Date of Cremation:
Retort: G Tk 4(j 4:70 IF,
Time Cremation Started: Lf
Time Cremation Completed: / 2�
Type of Container: V—D
Remarks:
24. 1
" Home of NnturnI Beauty ... A Cood Plnie to Live "
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
ti o
P
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:
Marl I Ada ► n le.,
(NAME) (SEX)
1 M(x.Kina bj Yrnl Lane cuernShl.t n j Nly I ZBU4
(STREE (CITY) (STATE) (ZIP CODE)
who died on `111� day ofAuQu,--if2005
at J8117CK(io b!►r d Ln. (91)PP n5JO ,rz 1 , W
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
ftaLL-�) AcAo INAricLorhirr] Lo - Ooe-eio<� I-J,
Relationship to deceased r 1w a nd
Name of Funeral Home BREWER FUNERAL BIOME. INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased 4haor has no pacemake in 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
ag st them by reason of or connected with the cremation of said remains as directed, whether
su h laims or demands are or are not wholly groundless, false or fraudulent.
y Lf
f
IGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: (Os—