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LNE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name
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Date of Cremation
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Time Cremation Started
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Time Cremation Completed
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned mWests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains of
Gloria Teele Female
(Name) (SQK)
3230 Church Street, Valatie, NY 12184
(Street) (city) December
(ZIP Code)
who died on 7th days December 20 09
at Barnwell Nursing& Rehab Ctr,Valatie, New York
(fie) (Address)
Name and address of nearest wing relative or name of person authorizing cremation:
Honey J. Hollen 276 Scotchbush Road, Burnt Hills, NY 12027
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Brewer Funeral Home, Inc
IMPORTANT:
I represent that to the best of my lanovrledge,the deceased(has)or .dWbSator,battery battery packPoww
cog,radioactive implant or radioactive device In his or her body.(CUcle )
I certify that I have ful power and authorization to arrange for the cxemadon of the remains and to direct the dlspoekion of the
cremated remains.that any personal possessions hem either been removed or may be destroyed.and agree to protect,defend and
save harmless Pine View trematarks m from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with the cra n ofteid remains as directed,whether such claims or demands are or are not whoky
groundless, or fre ul
(Address)
and Address of RelaWe or Legal Representative)
signed on this date. 12Z /Zvi
Disposition of Cremated Remains
1 hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mad to
Other arrangements-Please specify.
If pndverization of crenated remains is requested,check here X
Revision:Aprk 18,2007