Gamble, Anna l
rrnq+N OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :-'EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director .9&-r(gN—
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Name "/Y /(/�,�,� Case # Js 3
Date of Cremation ] pZ� o?CLT`
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Time Cremation Started 'dim J
Time Cremation Comoleted t#1 /
Type of Container � /9 riAP, C�,�
Remarks :
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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
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
ZZ �f7�C�CY
(Name) (Sex)
(Str et) (City) (State) (Zip Code)
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o died on day ofd,�
(Place) ( dress)
and address of nearest living relative or name of person
izing cremation:
ne) (Address )
,ip to the deceased -
feral Home
that to the best of my knowledge, the deGe.ared,-has -Or
naker in his or her body. (Circle One)
at I have the full power and authorizat ,,an ,t;a;;zar3ge.G
ation of the remains and to direct the d $pgs: torb�of
remains, that any personal possessions have either
or may be destroyed, and agree to protect:; def,(igdaiamd.5
Pine View Crematorium from any and:. a--l ,Clainta9'.mod
oss or damages which may be made against sby
connected with the cremation of said remains as
:her such claims or demands are or, are;, �noA grJy3
Ise or fraudulent. ''" C.
PA AAa
(Address)
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Sigrof Relative or L al Rep. and dress)
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