Simon, Ned TO'7 N OF QUEEN.,5BWZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
r- AWFuneral Director� E �'S �
Name Ilf 61 n A 411
Date of Cremation 1 — y
Time Cremation Started
Time Cremation Completed IQL �o
Type of Container
Z IF
Remarks:
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416 4&-10
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REGANIDENNY M2346 PAGE 02
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New, York 12904
Phone (81B) Crematorium 745-4477 or• if no answer
Cemetery 745-•4476
AUTHORIZATION TO CREMATE
The undersigned requests end authorises pine View Crematorium, it+
accordance with and subject to its Rules and Regulations to
cremate the remains ofl
—MPCA P)QY7 Man
(Name) (SeK)
(Street) tCit (•Statel , IZip Code)
who died on day of
xt
(Place) (Address)
Name and addres
Ith of nearest living`/ relative or name of person
� r r ion: 13y9F C,
c en_
(Name) (Address) cc__
Relationship to the deceased _ �y� s
Name of Funeral Hose crion �i�.� r- „ C0171C�+q,r p r
IMPORTANT a
I represent thit 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 t?ie full power and wubhorisativn t0' arrange
for the cremation of the remains and to 'dirict the disposition of
the cremated .remains, that any personal.. ppsse,•saions have either
been removed or may be destroyed, and agree to protects defend
and save harmless Pine View Creeatoriun from any and - all claims
and demands for loss or damages which may be mode •against thew by
reason of or . connected with the aremotior7 ' of Laid remains as
directed, whether such claims or demand` are or are not wholly
groundlessl , false z
fraudulent.
O
(W'tne ) ipddress) 17;0 S. 701
(Signature of A ative or Legal Rep. Ad Addresa)
Signed on this dotal_- -