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Duda, Frank TOTVN OF QUEEM5BU y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, I EW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director N a m e ��/���21@1111111BIW kVgd C a s e # Date of Cremation � '"' o�.� Time Cremation Started Time Cremation Completed9.'r4© i9 fm?) Type of Container Remarks : 1711 �3� 19//Q 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, in accordance with and subject to its Rules and Regulations to cremate the remains of: Frank John Duda Male (Name) (Sex) 118-35 Metropolitan Ave,B-3 New York City,NY 11415 (Street) (City) (State) (Zip Code) who died on 18th day of July 2000 at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: Damian Duda 30 Dupont Ave., Piscataway,NY 08854 (Name) (Address) Relationship to the deceased Son Name of Funeral Home Carleton Funeral Home,Inc. IMPORTANT: I 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, 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 cremation of said remains as directed, whether such claims or demands are not wholly groundless, false or fraudulent. Carleton Fzin­,al _Home, Inc. (Wit ss) (Address) .,� 30 Dupont Ave. , Piscatawa /_7 (Siglture of Relative or Legal Rep. and Address) Si on this date: