O'Keefe, Richard TO 7+N OF QUEENs5BU�Ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name f'� f�i� r 11� / Case # '7y ',
Date of Cremation
Time Cremation Started t�✓�/g//{/� r
Time Cremation Completed < LQ & M ,
Type of ContaineroCAAV,&A" Z- ��/�J�,�"a�"
Remarks :
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08/23/20e0 09.10 518-745-4474 T 0 �LJEENSSURY PAGE 02
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Load, Queensbury, New York 12804
Phone(518$'Crematorium 745-4477(it no answer)
Cemetery 745-4476
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AUtHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject fits Rues an�eguiation a cremate the remains of:
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(NAM EI i (SEX)
3Y '0 R 7'- 30 &2 6WIL
(STREET) (CI Y) (STATE) (ZIP CODE)
�7 D C
who died on_ _ �Y "��[ day of --W,4 20010
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at
(PLACE, (A RESS)
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Name and address o`nearest living relative or name of person authorizing cremation:
xx
10
Relationship to deceased
Name of Funeral
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IMPORTANT
I represent that to the best of my kn wledge, the deceased has or F r pacemaker in his or her
body. (CIRCLE ONE)
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I certify that I have the full power anO authorization to arrange tnr the cremation of the remains
and to direct the disposition of the cromMed remains,that any personal possessions have either
been removed or may be destroyed,f and agree to protect,defend and save harmless Pins View
Crematorium from any and all claim and demands for loss or damages which may IN made
against them by reason os or conner led with the cremation of said remains as directed,whether
such -aims or df:mands are or are riot wholly groundless,false or fraudulent/4,0 f4f�/e� Z��/
(WITNESS) (ACICRESS)
(sIG.N#TURE OF RE.LAT MR LEGAL REP.AND ADDRESS)
Signed on this date: �a4 ---
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