King, Phyllis TOrRN OF
QUEEN
BUr
PINE VIEW CEMETERY AND CREMATORIUM
�y
QUAKER ROAD, QUEENSBURY NEW PORK 12804
(5 18) 745-4476 (518) 745-4477
p Funeral Director
-Name
Case# 39
Date 01 Cremation
Time Cremation Started
Time Cremation Completed 10 , g0 h
Type of Container .,r v r � �ower
Remarks T
• 10r Oo
07�06
3�,
TOWN OF QUEENSSURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (if no answers
Cemetery 145-4476
AUTHORIZATION TO CREMATE
The undersignee eauests and authorizes Pine View Crematorium. in accordance with ana subject
to its Rules an Regulations to cremate the remains of:
E) (SEX)
Ph
�/ J
(STREET! (CITY) (STATE) (ZIP CODE)
Nwno died on if day of c0
at
(PLACE'+ (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relatinnship to deceased l�a�
6 4�P4
Name of Funeral ~come BREWER FUNERAL IIONE, INC.
IMPORTANT
I represent that to the best of my knowledge, the deceased has �as �pacem�akern 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
against them by reason of or connected with the cremation of said remains as directed, whether
such claim o demands a e or re of wholly ou dless, f Ise or fraudulent.
(WI 5) (ADQ
(SIGNAT 'RE OF I RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this da;1: 7 31 0