Miller, Sheri A.
(""""KN OF" QUEEVBU-I�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /61/1 / (�
Name Case
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Date of Crema} ion
Time Cremation Started
Time Cremation Completed 13 P 4" p-ffi.
Type of Container __lam f P)p/1Ng �� 11 , e z�
Remarks : ";r�06—
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I OWN OF UUEENSUURY
(LINE VIEW CEMETERY
11
•' CIIEMII IUR I UM
puairer (7rricl, IaUeelltl)ur'y, New York 12904
Phone (5113) Crematorium 745-4477 or if no answer
Cemetery 745-4476
f1UTI lUR I Zn I-l ON 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 :
Sheri Miller fPm 1P
(Name ) (Se")
2 Poplar St------- __.Hudsnn Fad --------- NY
(Street ) (City ) (Zip Code)
July 19 96
who died an 13th ______ . -day of
at 2 Poplar St, Hudson Falls,.-NY 12$3,2_—
(Place) (fl(jr.ir•ess )
Name and address of nearest living relative or name of person
authorizing cremation :
Douglas Miller 2 Poplar St. , Hudson Falls. NY 12R*IQ
(Name) (Addr-un )
Relationship to the deceased husband
M. B . Kilmer Funeral Home
Name of Funeral Home
IMPORTANTo
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 ally 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 .
(Wit-ness ) (Address)
(Si nature of Relativeor egal Rep. and Address)
Signed on this date :