Hall, Matthew T. Sr. jotul'b U �ee�2:s GLNI.�
FINE VIEW CEMETERY incl CREMATORIUM UU
QUAKER ROAD, QUEENSDURY, NEW YORK 12801
(518) 798 4726
(518) 793-9777 V
Funeral Dirictor
Case No.
Dale of Cremation
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'Time Cremation Started � !�
'Time Cremation Completed - t00
of Ccmtainer ��/J/1
Permar.ks
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I ( 11
TOWN OF RUEENSBURY
PINE VIEW CEMETERY �T b
ac
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Name Sex
Street Z
City State Zip Code
who died on C/ day of C 19
-67
at- � _ � )
(Place Address)
Name and address of nearest living relative or name of person authorizing cremation:
(Name Address
Relationship to the deceased I)
Name of the funeral home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o nojacemaker 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 �
Signature of Relati a or Legal Rep.
_yPvc-
Ad(lress) Address
Signed on this date JJC�. y