Sioui, Roger TOWN OF QUEEN
,s5BU9ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case # ��
Date of Cremation L�J
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Time Cremation Started /! oZ- LI 1
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Time Cremation Completed y � 040 Pf-
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Type of ContainerCIZ
Remarks :
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745.-4477 or 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 :
--L) ci e-/-
( ame) (Sex)
PIP 461- 1 A e u
(Street ) City) ( tate) ( Zip Code )
who died on _ S day of 19
(Place) (A ress)
Name and address of nearest living relative or name of person
authorizing cremation :
P0 .
(Name) ( ddress)
Relationship to the deceased
Name of Funeral Home'
IMPORTANT;
I represent that to the best of my knowledge, the deceased has or
►ono pacema a his or her body. (Circle One)
y 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 such claims or demands are or are not wholly
groundless, __f..a st or raudulent.
kJ �—
( fitness ) / (Address )
(Signat re of Re ive r Legal Rep.' and gAddress)
Signed on this dater 6 4- I lA,