Carey, Irene TOUN OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director .�NS/b?0�.�
Name .�Q�/1i,� /(�� Case # 02 02.
Date of Cremation 7 — !J
Time Cremation Started
f ,r�
Time Cremation Completed
Type o f C o n t a i n e r ef, / ��5.� p/� ]—/`,•� �7jn y
Remarks :
11 y9i9iti� %
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TOWN OF QUEENSBURY
PINE YIEW CEMETERY
CREMATORIUM
Quaker Road, Oueensbury, New York 1ES04
phone (Oie) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes pine View Crematorium, in
accordanCQ with and subject to its Rules and Regulations to
cremate the remains Of:
f� �. � td✓ w\a
(Name) (Sex)
a rGq
(Street ) (City) (State) (zip Code) q
day of t. L lq l3
who died vn
(place) Address)
Name and address of nearest living relative or name of person
authorizing crematiOne
(NamI (Address)
-A Relationship to the deceased
-1-
Name of Funeral Home E
IMPCIRTANTt
I re rep that to the best of my knewledgef the deceased has or
has no pacemake 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 possession% have either
been removed or may be destT=oyed, and agree to protect, defend
and save harmless Pin* View Crematorium from any and all claims
0"4 d,eMa"ds fel• less er domAg4o which be m,sdo 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
ro le f or fr&%Ldulent. �9
�- ,,,i _ r.AM va. r. _
'000, (Witness) (Address) p
( 'nature elative or Legal Rep. and Ad sass)
Si ned on this dates