Jenkins, Doris rl OrNN OF
QUEEN,5BUr
;�'
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
'TT 1g3 Funeral Dire ctor�REWE
Name 0(' s VCn�
Case# SS
Dace Of Cremation Z
em60
Time Cremation Started 1; K A
Time Cremation Completed V(Q
Type of Container tiro GrU IST Ci45
Remarks
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Coat 7 ' 10 ,q '7
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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: r
+C Sex
Name
City State ZIP
Street
who died on I day of
ri n
at Add;Ts
PIS
Name and address of nearest living relative or name of person authorizing cremationin
Relationship to deceased Y
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the hest of my knowledge,the deceased has has no pacemaker. 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 ddii p ition
of the cremated remains,that any personal possessions have either been removed or may destroyed, s or dam-
to protect,defend and save harmless Pine View Crematorium from any and all claims and demands for loss or damag
remation of remains as directed,whether ed,
ages which m:a made against them by reason of or connected with the c
wheteher such claims or ands re or are not groundless,fals fraudulent. 1
Witness Address
IGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE)
signed on this date i 2