Jordan, Donald rl-OWN OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name A [j�= I) Case #-�
Date of Cremation C ^ d
Time Cremation Started `� y 5 A n1 ,
Time Cremation Completed d` ' S6, 0 M
Type of Container 04k-A-
Remarks :
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Jan-25-01 11 : 55A P.02
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TOWN OF OLiEENSBURY
p pds V[EW CEMETERY
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CREMATORIUM
Quaker Road, Queensbury, Now ,cork 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
edema the regains oFt pp
'J lorz J10 Kr (SON)
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(street) (city) (State) (Zip Code)
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who died on _ day of
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at S 14 l
(mace) (Address)
Name and address of nearest living relative or name of parson
authorizin ere matio`t � �Q �A�
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(N me) (Address) '
Relationship to the deceased
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Name of Funeral Nome, auou sue
IMPORTANT t
I represent that to the best Of my knowledge, the
he)deceased has or
has no pacemaker in his or her body.
I certify that 1 have the full power and authorisation 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 V1ew Crematorium from any and all claims
and demands for loss or damages which may be made against them by ;
reason of or connect,d with the cremation of said remains4 as
directed, whether such claims Or demands are or are not wholly
roundless, fal a or fraudulent.
o QA
tWi Hess (Address)
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(Signatu a of elative or Legal Rep. and Address)
Signed on this datei_�. .�?�