Holland, William rrn'MN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
l , Funeral irector - IZ_
Name U/ , �,� j A/Vl, Hd raJ"� Case# �Py
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container c,4,,Nr-d ` c?j+IZC�
Remarks
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Town of Queensbury !� l✓ "
Pine View Cemetery
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CrematorrUm
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:
Name Sex
� gam
Street City tate Zip
who died on c2 day of 20 0-S
place Address
Name and address of nearest living relative or name of person authorizing cremation
Relationship to deceased
Name of Funeral Home BREWER FUNERAL HOME, INC. `
IMPORTANT
I represent that to the hest of my knowledge,the deceased has or has no pacemaker in his or her bcA(CIRCLE ONE)
1 certify that I have full power and authorization to arrange for the cremation of the retains and to ddect the disposMton'
of the cremated remains,that any personal possessions have either been removed or may be destw#W,meld agree
to protect,defend and save harmless Pine View Crematorium from any and all claims and demands for ime 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,
er such claims or ands are or are not wholly groundless,false or fraudulent. ;.
Witness Address A` ,
r
(SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
•
signed on this date
Y .