Coppersmith, Beverly - ' ro WN OF QUEENsB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ddL6 `A �'`
Name JI
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Date of Cremation
Time Cremation Started Zzt� /fly r
Time Cremation Completed 1 LOCI P"tA I
Type of Container CAM K::ZQZ-// cakh'�T W,lyoC8�C— df-7-#W-a
Remarks : l hj)FO- KP
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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
iie 'undersigned requests and authorizes Pine View Crematorium in
,_
atc6 rdance with and subject to its Rules and Regulations to cremate
tfie remains of:
(Na
(Sex)
(Street)
;v�:, , . (City) (State) (Zip Code)
Ao' died on day of v
at
(Place) (Addy ss)
Nye and-address of nearest living relative or name of person
d hori2ing cremation:
Y,
(Name)
1;�b„1aat,irnship to the deceased
Name of Funeral Home
IdRTANT:
Iq�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 or are not wholly
groundless, f lse or fraudulent.
(Witness) (Address)
(Signat of Rela i v e r Le al Rep. and Address ) /ilyi7
Signed on this date: �j7r _