Knight, Kathryn i
.4� O�� OF QUEEN B2.1J�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4-476 (518) 745-4-477
Funeral Director
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=ate Of Cremation_
Cremation Started 1 0y Q - M
ce Cremation Completed
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TOWN OF OUEENSUURY
PINE VIEW CEMETERY 15
3.
CREMATORIUM
Quaker Road. Queensbuiy, New York 12004
Phone t510) CtelT atuHum 745-4477 (it no answer)
Cemetery 745-4476
AUT1-10RIZA1ION 'I0 GREMAI E
The undersigned requests and authudzes Nine ViLsw I;1u111 Iu1,L,m. in accuidance with and subject
to its R es and Regulations to ctemale the iemains ul:
(NAME) (SEA)
(STREET) (CITY) (S rA l E) (ZIP CODE)
who died on I r day ut
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of petson authorizing cremation:
ink 44
kJ
Relationship to deceased SSA
Name of Funeral Home 1 6N Q
IMPORTANT
I represent that to the best of my knowledge, the deceased has o"�� 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
such claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) A DRESS
A - 1 �A na�:4�,
( IG ATURE OF RELATIVE OR L AL REP. AND ADDRESS)
Signed on this dale: \,