Brough, Mary E •
•
Funeral Director: 14 3 R-}" (-) B 1-
Name of Deceased: /" A 12 B f O v (,J+
Case Number:
Date of Cremation: 2‹ — 2 - - 1
Retort: 1 c) R-
Time Cremation Started: 1 . I 0 fs ' v
Time Cremation Completed:
Type of Container: CAA tiZ 9 p»/4-rz C) /' ' k)
Remarks: ' Z 0
1 9,0 Pell
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7 LID
•
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 requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
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cremate the remains of:
"lite 4/ C, epo G1 Q A
—! J " c(Name)
- �/ (Sex)
(Street) / (City) (State) (Zip Code)
who died on / 7 day of Citel Y,f' 200s
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
X416,r) (7 f ro 1 /6r120 s• i� e C4es to
(Name) (Address)
Relationship to the deceased
�d 1�
Name of Funeral Home cteer "-r 44-6
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) • (has no) -cemaker,defibrillator or any other battery operated
device in hisoc her body. (Circle One)
I certify that I have fulrpower 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 daims 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 daims or demands are or are not wholly
groundless,false or fraudu ei� // `
"/"7. AttS> /9111&/,
(Witness) (Address)
ignature nd Address of Re( or Leg epresentative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:July 7,2004