Loadholt, Neil i
1'it,c view C;e:nteC.ery C� C;re 11,111)
(�ual:cr ROwl
(, ucctlsbury, NY 1280xi•
(i 18) 741 )-4,1.77 or V) 18) 7/1-Swl-47(i
l'ttncr,tl IIott,c
Recic�cstc<I Rclurn `1•itttc �
bate of Crcmalion s/ ��9
-----y I unc Sl;utccl /C?ZS' I u„c C.:OMpictc<I �f s
Typc 01�Colibullcr _
n_y�
Rcnuu•ks I
I
maid
----------------._....--------�------ ...------------ IVIc��•c_ far? �
('lace of
h;suimllccl 'Alci;;ltl c>I' Itctnains ,ulcl (:onliiincr--_---Zoo
- . _.
l);Uc 'finis Rcntaitls ilrrivccl al ( rctnalor�
Name of I uncral l)ircet.or or Rcgislcrccl Rcsicic:nl Dclivcrim Rcttuuns 1
Deiailc.cl rc;is<>n I'or cickky 11'rc;immis Nvcrc c.r
cclivcry cicucc nu>rc Ilrut 68 otus Irolt lnts o acesIticc
- — _..- -- — .--------------
1 um( Nuntl)cr ill wltic:lt ftctttains wuc c•rcinalccl__
Nolc:'I'Itc; Cl.ellt,c
lionrcl>imccl i . .
n Ilic l c_i iti.titcitl I`ll •
Authorization for Cremation and Disposition
(Inifal the following)
I/We understand that if the remains are not claimed within 120 days of cremation,
Pine View Crematory may dispose of the remains in
(Name of Crematory)
an irretrievable manner, such as by scattering.
CREMATION CONTAINER/URN
(initial ONE of the following)
An urn to be used as a container for the cremated remains has been purchased from Brewer Funeral Home, Inc.
and is described as follows: ul L)ryc
I/We understand that if the urn is too small to hold the entire cremated remains, an additional rigid container may be used for delivery.
-O'R'-,
hJ An urn is not yet purchased. I/We understand that if no urn is purchased or otherwise provided
Pine View Crematory
will place the cremated remains in
(Name of Crematory)
a rigid temporary container for delivery.
Patricia Miller
This Authorization Form was provided by was executed at
(Funeral Director Name)
Brewer Funeral Home, Inc.
24 Church St., Lake Luzerne, NY 12846. (Funeral Home Name)
(Funeral Home Address)
and is signed by the funeral director as witness to its execution.
I/We have received a completed copy of this Authorization Form.
The person(s)identified below is/are the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained in this Authorization Form and authorize(s)the foregoing.
Signed this 13 day of May 120 19
I
c r �� Imo WA i A Ar,41-
Ty d or Printed N ignature
Typed or Printed Name Signature
Address
Typed or Printed Name Signature
Address
WITNESS:
Patricia Miller
(Funeral Director Typed or Printed Name) (Funeral Director Signature)
12465
(Registration Number)
�-
(Name of Deceased) j
DOS-1898-f(Rev. 08/15) Page 3 of 3
I
I
,
~
—
^ , n�uiu/Y & Cmn;'kx Imo
Quccoxi/(j/y` NY / 28()4
. [� | H) 7'1,5'4' 77 0/* [Ji8) 74,5'/k476'
| !
moc �~
�-- -~~"=��__'--
� Nxon__ / l � mc
�7�'—'---_---__(�`oc N" ~� ~� �-- "
� �
//x� o/ (�nzmm�oo � � - -------------
lyy« V[(�n/(»ioo�
~ /� . ��
------~=w�^�'--�~"m�&�&�u���. ^�"���� /U
-----��_e-
—_-'-_-------__-_----_------_--
|<coxo1s
h4xi/) ____
k4o,x___^/^�*
|1x"' n[�cx<// �- / � / � ----------------
} VY --
o c��U
c /�
�» '(�x�x
~ .oxxuox an1vcJ x� ()ooxkxy_�_���� / �V -�
3----_---__- 0p,,�
Mxxvc o[F\x1cm| N/�ckor
� Dc|al|eJ ,c^ ��x� '|J``y i[/zo`^io" `,n, ',,v`;ocJ o`o/� Uwn �8 | � ---~-~==-------
oo',cq( ' «»o� hmo (inno[
xrcc!Vo|
---------------------------_--___--__--.-_--_-------_-_---------_---------- '
-------�
Duo� Non`!m� III which Rnoxiox `,c/c nnox|cJ �� ------------------
--_��~~-`--����---�����_'--------------
�^
�
NNo'DnCmna(loo {o,'| III U/c |`ooxvlco| I'll(: o[/|,c C/oo^|o/ly