Murphy, Elizabeth viilTrA7 t..tb Cj. • ..r ... .r.r
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T- 0- TI/AN OF QUEEVBURY
PINE VIEW CEMETERY J AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director17 Al
Name 1k // Case 11
Date of Cremation
Time Cremation Started '
r
Time Cremation Compl et eddld, 3d dl M � �
Type of Container 4219RDS64fl D 1:5- , ,Cd,e cltc A
Remarks :
19 �M
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i
TOWN OF QUEENSBURY '
PINE VIEW CEMETERY
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:
(Nam )e (Sex ) 1
�X (16 ��P ��� W. / _
(Street ) f (City ) (State ) ( Zip Code)
who died on ` day of A0 'r,. 19�
(Place) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
11,4", . 10 A' P 4 V
(Name) (Address )
Relationship to the deceased ''l
Name 'of Funeral Home-visM.ac- ^¢�y
IMPORTANT:
I represent that to the best of my knowledge, the decease Chas)
has or
has n pacemaker - n his or her 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 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
groundL s.,._.- a-1se or fraudulent . C - off v r
i tness> (Address )
l
(Signature of at a or Le
gal Rep. and ddress)
Signed on this date : `—t/v 1