Ormsby, Linda ' rn%N OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � " `_
Name �`�-1 ��, �. ��/� ( Case#
Date Of Cremation
Time Cremation Started d ��
Time Cremation Completed —3
Type of Container C \3(3 �?.�
Remarks
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 d Regulations to emate the remains of:
V-41�- /k 12 1-,A)w
Name Sex
Street city State Zip
who di on YEZ day of 20�
at
2
place Address
Nam and address of nearest livi relative or name of person authorizing cremation
}
Relati Iship to deceased
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased haas as no pacemaker in his 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 ad,
wheteher such claims or demands are or are of wholly groundless,f e or fraudulent.
Add r ss
(SI
GNRE F RELA OR LEGAL REPRESENTITIVE)
signed on this date