VanCarples, Bertha 70WN of QUEEN,5BU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
N a m e 06F 1 I- /-/ 104 C41(p 'E-5 C a s e #t 99 021
Date of Cremation �—/ —99
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Time Cremation Started �'
Time Cremation Completed /'L'o
Type of Container 1s7tc
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
The undersigned requestsAUTHORIZATION dautoriz0esRPineEView Crematorium
accordance with and subject' to its Rules and Regulations , to
cremate the remains of:
VAN C4.24e S
(Name)
--. (Sex)
3 � G✓YXtc.,�l�3wze ,,/y ter
(Street )
(City) (State) (Zip Code )
who died on y
day of 0IF
at
19�
(Place) (Address)
Name and address of nearest living relative or name of perscn
authorizing cremation :
K L. _AAdL 0 Z
(Name ) (Address ` '
Relationship to the deceased —
Nave of Funeral Home 1h"rX1q'- _ , C�✓/ -�1112�Ze, �A_A�
IMPORTANT:
1 represent that to the best of my knowledge, the deceased has or
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 them b�
reason of or connected with the cremation of said remains as
irec d, whether such claims or demands are or are not wno : : '
; ground ss, false or fraudulent.
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G✓�2121--M1.i/.'u2ti� ,may
Wit ess ) (Address )
Signature of Relative or Legal Rep. and Address)
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