Peters, Leon '77-17+N OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
ame /�-��� ��A C1Zez, Case; J?
Dayte Uf Cremati.on I
Time Cremation Started ,0
Cremation Completed 10
Tvpe of Container "
Remarks
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TOWN OF OUL=ENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone 1518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Giematonum. in accordance with and subject
to its Rules an ulations to cremate the terrains of.
L Q vr1 S
(NAME) (SEX)
(STREET) (CITY) (S ATE) (ZIP CODE)
who died on day of 20 y J
01
(PLACE) (ADDf S)
I
a e and ss of nearest living relative or name of person authorizing cremation:
Relationship to decease2�
Name of Funeral Hom; ; -
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
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
7sucJIa' s de ds are or are not ho lly_g round less, false or fraudulent.
(WITNESS) (ADDRESS)
PeA
( NATURE OFr� ATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: