Gray, June uY.k:s_s1_G
To` +N OF O UEENSB U-qq "
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &)EXA 9joQ ` , A� kze
Name y Case #T
Date of Cremation /� �a-3 W
c Time Cremation Started c'S-1 /,QQ w (
Time Cremation Completed .1,5a ! M(
Type of Container /C
Remarks:
�N �R 01 /�71A4
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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:
June T. Gray F
(Name ) (Sex)
20Third Ave. , Warrensburg, NY 12885
(Street ) (City) (State) ( Zip Code )
who died on 21 day of Oct. 19 98
at 20 Third Ave. , Warrensburg, NY
(Place) (Address)
Name and address of nearest living relative or name of perscn
aut'-iori z i ng cremation :
Ira Gray 29 Oak Street. Warrensburg, NY
(Name ) (Address)
Relationship to the deceased Son
Name of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased rXWXXX
has no pacemaker in 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 , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against there bti
rniaso
of or connected with the cremation of said remains as
d ether such claims or demands are or are not wholl ,
g s false or fraudulent .
/IC-vJt
(W * (Address )
i
(Si a ure elative or Legal Rep. and Address)
Signed on this date : October 22, 1998