Walker, Donald 70%N of QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Dire ctorA r9g��/y�j
Name Lbb) aIS2 � Case # ,
Date of Cremation LY2- - gic /
Time Cremation Started
Time Cremation Completed Pr M
Type of Container i9n 4D
Remarks :
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02 i;3� �!M
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TOWN OF QUEENSBURY
PINS 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:
le
(Name) (Sex)
( Street) (City) (State) ( Zip Code)
loe
who died on 114 day of
at �is JZ �.t'���� �'��drr.-s` /Uy
(Place) 11 ( ddress )
Name and address of nearest living relative or name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased,e� / /r
Name of Funeral Home wwyl -r 1/ltif --�iv�•
IMPORTANT:
I represent that to the best of my knowledge, the deceased hAs_or
has no pacemaker in his or her body. (Circle One) SID
I certify that I have the full power and authorization„ to a,�Fa�ge
for the cremation of the remains and to direct the dis'pos�tYon of
the cremated remains, that any personal possessions have Other
been removed or may be destroyed, and agree to protect, defend and
save harmless Pine View Crematorium from any and all clai^ p-And
demands for loss or damages which may be made against : ,them-.rby
reason of or connected with the cremation of said remains' as
directed, whether such claims or demands are or are not wholly
groundless, false or fraudulent.
(Witness) (Address)
igna ure of Relative r Legal Rep. and Address)
Signed on this date: 10/