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Gunty, Anne r'-o%N OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director lv -0 Name A(L"( f— Case # 5 s Date of Cremation 4--- 7 Time Cremation Started r0 Time Cremation Completed I;� . 3d P , 17 Type of Container bcJvod QQ1} i�-n,L C,AS,e 0 /h-e Remarks : Mr-c i N, /0 i TOWN OF QUEENS©URY PINE VIEW CEMETERY a CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (516) 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: (Name) �m//e (Sex) ,¢) /////���x//n, (Strhet ) (City) 7-(Stat--ee) (Zip Code) who died on / day of �'`?1�'fu� 19 �� . at t E 7 2 / az CGS G (Place) (Address ) Name and address of nearest living relative or name of person authorizing cremation : /.,, 14 �2- (Name) 17 (Address) Relationship to the deceased Sa-r _ Name of Funeral Home _ IMPORTANT: I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (C.ircle One) I certify that I have the full power and •aut:horization 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, defend 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 cremat.lo.n of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent . (W t ) (Address ) i�glignature of Relative or Legal Rep. and Address) Signed on this date : o-/I, Aq Sent oy: SEXTON 7084490177; 1211 5/99 3:35PM;jjL&& #,102;Page 31 4 y'9.0 Recelve7: 12115!99 B;IbAM; -+°SEXTON; #00i Pago 2 J 12115/1959 09:53 518-792-1237 RFGAN&DENNY 01346 PAGE 02 � I I TUWN OF OUEEeNSOUPY p►jW VIEW CEMETEnY CnEMATOR I UM Quaker Rood, Oueensbury, New York 12804 Phone (518) Crematorium 745-447'7 or if no ons►+er Cametery 745-4476 AUl')•MU ZAT t ON TO CREMATE The undersigned request ; and authorizes Pine View Crematorium, ire accordance with and subject to its Rules and Regulations to cremate the remains vf: .�.»t (Nate 4 (Sam) _ B04f Istr et ) (City) (State) (zip Code) who died on day of 19�--7- dC (Place) (Addras�l Name and address of nearest living relative or nacre of persorl authorizing cremation : j (Na a) 4Address) Relationship to the deceased—so"- • Name of Funeral Home yL , i IMPORTANTs I represent that to the best of my knowl94ge, the deceased has orb n,66 no pacemaker in his or her body. (C4rc)e One) I errtify that I have the full power and -authorization to arrangd for the cr(taation of the rema►jn* .and to direct. the disposition of the cremated remains, that any personal possessions have e)therw been removed or may be destroyed, and agree to protect, defwnd and save harmless Pine View Crematoriums from any and all claims' and demands for loss or damages which may be grade against there by! reason of or connected with the cremation of said remains as! directed, whether, such claims or demand'f are or are not wholly groundless, false or frati,dulept. (W (Address) I i nature of Relative or Legal Rep. and Addraeol Signed on this dates /� ��