Cleveland, Earl TOq+N OF QUEENs5BUPY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director a 1 0
Name i )9 e #
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Date of Cremation
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Time Cremation Started V ��
Time Cremation Completed 1 r
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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 subject' to, its Rules and Regulations to
cremate the remains of:
Earl J. Cleveland _- Male
(Name) (Sex)
858 Peaceful Valley Rd. North Creek New-�York 12853
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(Street ) (City) (State) (Zip Code )
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who died on 27th day of May 1999
at
858 Peaceful Valley Rd. North Creek, new York 12853
(Place) (Address)
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Name and address of nearest living relative or nave of per5 .—
authorizing cremation :
Mrs. Sharon Cleveland 858 Peaceful Valley Rd. North Creek, NY 12853
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased rI�
has no pacemaker in his )0Q0QQ9iX body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of t-he 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 , defenz
and save harmless Pine View Crematorium from any and all c ; a : ms
and demands for loss or damages which may be made against them
reason of or connected with the cremation of said remains as
directed, whether s h claims or demands are or are not "no : '. .
gro ndless, false or f audulent .
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(Witness (Address )
(Signature oY Relative or Legal Rep. and Address)
Signed on this date : May 30, 1999