Scheins, Anna • uY.J2ia2c� ........
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.O OF QUEEN
s5BWZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ) /` ' / k lam'
Name AlYNA �i/7 '/�/�� Case # /
Date of Cremation oZ O — 1 w
Time Cremation Started �i� d
Time Cremation Completed
Type of Container 4,bQ2
Remarks :
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11 iI 1;Is
1/ 11 )7,'
TOW OF OUEENSBURY
PINE VIE6! CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 775-4471 or if no answer
Cemetery
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 ofs
fi
(Sum)
(Name)
(street ) (city) Sta e) (Zip code)
��MB� �
who died on A!!i day of l9
v
at10 u S
(Place) (Address)
Name and address of nearest living elative or n86e of person
a thorizing cr mations
(Name) �(Address) n �
Relationship to the deceased P)g "'"
Name of Funeral Home c�
IMPORTANTs g the deceased has or
I r resent that to the best of my knowledget One)
has pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct
shaveteither
ion Of
the cremated remains, that any personal possessionsdefend
been removed or may be destroyed, and agree to protect,
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
undless f se r ffraudulent.
A AE�
(Witnes ) ��
(Ad ress �
(Signature of Relative or Legal Rep. nd Address)
Signed on this dates