Locke, Daniel P TOTIAN OF Qqqjy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name � �}�l l., P 1.oc K - Case#
Date Of Cremation 3 - o,v _ ZC�U
Time Cremation Started 'I 1 ,5 A
Time Cremation Completed 3 PNA
Type of Container YNrNZ3 0616 I2,c) � � J
Remarks
4
1 .55' F4\
4). 3 5 P")
3 /M
.--t 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 it ules and Regul ions t cremate the remains of:
)fi,t igibAe A.
(NAME) la)
/2.4 ..-.50 .idtetialk
1 AV 1,28%.414
(STREET) (CITY) (STATE) (ZIP CODE)
who died on /tF l 0 . day of 20
at )41 A1. /24; 14/44/ ;1z4 _
(PLACE) (ADDRESS)
Nan and addres of nearest living relative or name of person authorizing cremation:
1 iia -
Relationship to deceased 0/1e61.14
Name of Funeral Home BREWER FUNERAL HOME, INC.
a IMPORTANT
I represent that to the best of my knowledge, the deceased ha or has no pacemaker pacemaller..ji his or her
body. (CIRCLE ONE)
I
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
su,rJpms. br7Jjre
not wholly groundless, false or fraudulent.
WI S ) ADDRESS)
, e,-,k,_ i
(SIGNATU OF RELAT/VE OR LEGAL REP. AND ADDRESS)
Signed on this date: Vlam? \ ` `
I