Bissonette, Kenneth rl-o rUN OF QUEEM
5B URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :YEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name ffOW �;rf� fir'S�-Oj� ;rji Case # jyj
Date of Cremation (/" /— "q�
Time Cremation Started 61�oZ ABM
Time Cremation Comp let ed100 4tAL
Type of Container
Remarks :
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TOWN OF QUEENSBURY t
PINE VIEW 0rMETERY
&
CREMATORIUM
Quaver P,oad, Queensbury, Now York 12804
Phone(518)Grematorum 745A477(if no answer) `• � i
Cemetery 7464476
t#1 i
AUTHORIZATION TO CREMATE
The undersigned requosts and authorizes Pine View Cr,,.matorlum, in aczordanco whit land Subject i
to its Rules and k9gula.-ti-omens to cremate the remains of
(NAME) (SEX)
6-A"13 �v/ �le /1-1-LY -
+ (STREET) (CITY) (S T I.) (ZIP CObE) ,
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who died on _day of J U
(PLACE) (ADDRESS) JI
Name and address of nearest living relative or name of person authar{zing cremation; E
lSN7 cif � � fo�.3r-'►��? S-.lam' GM �it' �1.� 3 1
Relationship to decreased
Name of Funeral Horne&VSa_Ii�
IMPORTANT
I represent that to the hest of my knowledge, the deoeasod hqF or 2 no pacemaker In his or her
body. (CIRCLE ONE) i
i Cortify that I have the NO power and authodztAort to arrange for the cremation of the rern,�ins and
to direct the disposition of the cromated remains, that any personal possessions have either been
romoved or may be destroyed, and agree to protect, defend and save harmless Pine View i
Crematorium from any and c 'MS and demands for loss or damages which may be made ; I
against thorn by roaeon of r with tho cremation of said remains as directed,whether
auch claims or demands ar e t holly groundless, false or traudutent. i l
41
TN ESS) DDRESS)
(SIGNATURE OF RELATIVE OR L.E( AL REP. AND ADDRF-SS)
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