Blakely, Edmund a -
TOWN OF QUEENSBURY
P'lte View Cemetery nnrl Cretuntortnrn
21 Qonker Rond. Qtieenshory, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp lrw\v\v queensbury net
Funeral Director: ji� lt/
Name of Deceased: /VI 0 4 x.e k
Case Number: LI
Date of Cremation: — Ce 2p4 6i—
Retort: 0(ZALo Pb)z—f)
Time Cremation Started:
Time Cremation Completed:
Type of Container: OA- L8l 13/)L4 I)--J A4 ►are 0 12 3.;r'eh
Remarks:
r o N' nr ,irn1 6enuly .. A Con i Pl Lt � r
Town of Queensbury
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:
vrlC. talc (u b1l
Name Sex
d
Street City State Zip
who died on 2 day of S9 rk M � 20 _
at Kj 1 Z&-8
place J Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased_L—�
Name of Funeral Home BREWER FUNERAL HOME, INC.
�t
IMPORTANT ^�
I represent that to the best of my knowledge,the deceased has or has no pacemaker in 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 arty and all claims and demands for loss or dAl W 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,
wheteher such claims or demands are or are not wholly groundless,false or fraudulent.
Witness Address
(SIGNATUR OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date q�b-I(5_