Paschall, James TOq+N of QUEEVBUP,,YPINE VIEW CEMETER\ AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name!/ �J //JGT/ Case N
Date of Cremation /
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Time Cremation Started/V f,5o;7— 14 r
Time Cremation Completed /f 11'� / i I
Type of Container �J7/(�/ f,IY6: C/ J0?
Remarks :
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TOWN OF UIIEENSDURY • ., ..___...�_�..__. .
PINE VIEW CEMETERY
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C11EMA I'UR IUM
Qualter 17oat1, laueensbur-y, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
(1UT11OR I Z11T I 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 :
James T. Paschall, Sr. Male
(Name) (5em)
Coot Hill Rd. Argyle NY 12809
(Street ) (City ) (State) (Zip Code)
who died on 29th ----day of December lg 96
at Coot Hill Rd. , Argyle, NY 12809
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
jf)m. P 1 ,3kR;s&_, Pkcg —j040w.4 ti)y
(Name) (Addroun )
Relationship to the deceased !'(/
Name of Funeral Home M. B . Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or tier 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 possessions have either
been removed or may be destroyed, and agree to protects 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.
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(W ass) (Address)
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(Signatu e f Relative or Legal Rep. and Address)
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S gned on this date : 1' 7
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