Pino, Ronald T074N OF QUEEN,5BUP,.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �lJ�'/�JM6
Name .��1�,9,�� ?0/t Case N ID
Date of Cremation1—Z
Time Cremation Started
Time Cremation completed let, --5
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Type of Container LdADSOMD ZA t el
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY J p!7
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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 f:
(Name ) (Sex )
(Street ) (City) (State ) ( Zip Code)
who died on day of / _��+K-t.�r 19 7
at le 4 a
(Place) (Addre s )
Name and address of nearest living relative or name of person
authorizing cremation :
(Name) (Addres�/s )�
Relationship to the deceased V' Ir J 4--k«
Name of Funeral Home C-0e-Ab
IMPORTANT:
I re resent that to the best of my t<nowledge, the deceased has or
Chas no pacemak�e in his or her body. (Circle One)
I certify that I have the full power end 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, fa-lsse ^o�rf.raudulent .
(Address )
(Witness)
(Signature of Re ative or t_egal R and Addre
Signed on this date :