Fuller, Laurence rIOq4N OF OUEEM5B219ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorN
Name Case #
Date of Cremation
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Time Cremation Started �3C�,l�JIM
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Time Cremation Complete�dl ��dClifl(l �
Type of Container C�/f ��C�/7�� �� D��
Remarks :
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TOWN OF QUEENSBURY _
PINE VIEW CEMETERY j
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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 of:
�e� c c-. � � � l�e�.
(Name )
p (Sex ) y
(Street ) (City) (State) (Zip Code)
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who died on CQ day of 19�� ah ..� ar�f -
at aIc
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(Place) (Address )
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Name and address of nearest living relative or name of person
authorizing cremation :
(Name ) (Address )
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I repre_sen_t_ that to the best of my knowledge, the deceased has or
as o pacemaker i his or her body. (Circle One)
I certify that I have the full power 4knd 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
groun less, false or fraudulent .
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'(Witness) (Address )
(Signature of Relative or L4gal Rep. and Ad ress)
Signed on this date : 1-7 � �