Green, Maliki rl-nWN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /// .�L��Y
Name /Yf�/� /'�l [,"�� /x Case #
Date of Crematicn cf-! /
Time Cremation Started
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Time Cremation Completed -
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Remarks :
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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,
accordance with and subjece to its Rules and Regulations to
cremate the remains of:
Maliki Joseph Green Male
(Name) (Sex)
PO Box 67 Wevertown New York 12886
(Street ) (City) (State) ( Zip Code )
who died on 20th day of May 1999
at Glens Falls Hospital Glens Falls, New York 12801
(Place) (Address)
Name and address of nearest living relative or name of per5cn
authorizing cremation :
Mrs 6harlene Green PO Box 67 Wevertown, New York 12886
(Name ) (Address)
Relationship to t h e deceased Maternal Qrandmother
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of ray knowledge, the deceased XMQ0OD9
has no pacemaker in his 7UKXXXbody. (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 eitner
been removed or may be destroyed, and agree to protect , Oefenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them
reason of or connected with the cremation of said remains as
di ed, whether such claims or demands are or are not wnol : ,
roundless false or fraudulent.
"W - M
�(( (Witness ) (Address )
✓r
(Signature of Relative or Legal Rep. and Address)
Signed on this date : May 20 1999