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TO OF
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
Funeral Director f3' FLA.A) k. \�
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.e : e Of Cremation l `- t 9 — Z00 5—.
: :-a Cremation Started 11 14 0 1At "^-
-
. :• -.e Cremation Completed 95—,Ay
' . :e of Container.C44 -50fA•k 1
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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: ,
1 \ i d Q ti . a C1.Lu, i
Name Sex .
kt.t., qt\I 4-r(attuk_ >11 )dr8?)._<
Street City i State Zip
14.‘ i
who died on ( day of t_Sa vlu i '.- 20 05
� Q � -Y
at (P 50s qI V' .t G/J• I Z�I 3J/ A
place Address
Name and address of nearest living relative or name of person authorizing cremation
Taal'
Relationship to deceased AA .aA Y
Name of Funeral Home BREWER FUNERAL HOME, INC.
IMPORTANT
I represent that to the best of my knowledge,the deceased has as rw acemaker in 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 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 damage s or dam-
ages which m,e made against them by reason of or connected with the cremation of said remains as directed,whether ed,
wheteher such claims or demands are or are rot wholly grow less,false or fraudulent.
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Witness Address Yyl./ei,ti24‘t)/;)/ea4{.16-y(
(SIGNATURE OF RELATIVE OR LEGAL REPRESENTITIVE) ,
signed on this date c,yJtL /