Maney, Delores """WN OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director AI
a T e '�-f�1'� S M /=t 1J l Case# 2, <i _
ti ar e Of Cremation
_-e Cremation Started / J �•,,�
. :7e Cremation Completed � A/. "
� . Pe of Ccntainer
Pemarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Rine View Crematorium.in accordance with and subject to its Rules and Regulations to
cremate the remains of:
✓e tp e e res A J`�� K/e
(Name) (SOX)
I1,Ne(e t4 op j; ruby. A/�- l
(Street) (City) 9(State) (ZJp ram)
who died on day of I.,"'- 20
at G (4-el�� a�i��c 6 rzQGV-
(�) ) .
Name and address of nearest Wing relative aria, of Person authorizing crerrreaio a:
,g G-ZL o C L BYG r
(Name) ( )
Relationship to the deceased
/ t3 t) H'-4--n
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or ,no) ,dellbrillal r or any other battery operated
device in his or her body. (Circle One)
1 cw*that I have full power and authorization to arrange for the cremetim of the remains and to direct the disposition of the
cremated remains,than any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harm Pine View Crematorium from any and all claims and dwrrerrds for loss or damages whid may be made agairst them
by reason of connected with the cremation of amid remraans as dberied,whether such daims or demands are or are not wholly
9 n
(AdftwV
0
(Signature and Address of Relative or Legal )
Signed on this date: S�-ess— 6
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as bkms:
Mae to
Other arrangements-Please specify:
If pulverization of cremated remains is requested.check here
Revision:January 1,2006