Coughlin, Terence 2r0WN OF QUEENs5BU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C&k,,5 7Q/1(
Name / /�(C coL)"r ,I/V Case # IJ�
Date of Cremation -6
Time Cremation Started
Time Cremation Completed INY(I- /9 / All
Type of Container ay"X-D 73o'e�e-z3q
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
, t
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subject to its Rules and Regulations to cremate the remains of.,
(Name) :t.A
�) A) 5/ /«<t.1
(Street) (City) (State) (Zip Code)
who died on _-Fk _ day of ug
10
(Place) (Address) F
Name and address of r:earest living relative or name of person authorizing crer"atir'r��
Q
I _ Q�!
A)-
(Name) (Address)
Relationship to th'e deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best cf my knowledge, the deceased has or has o .
pacemaker in his or her body. (Circle One) ' '
I Certify that I have the fL11 power and authorization to arrange for the•creiravos -;:= past
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 ar'av d
to protect,-defend and save harmless Pine View Crematorium from any and all. p �
claims and demands for loss or damages which may be made against them ;-.3
try reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false orjraudulent.
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Fo I0 5 T G2N� ,s1uc_, i°l�f lam__fic�
(Witness) (Address)
(Signature o Relative or egal Ftp. and Address)
Signed on this date; _ ;� °� (', l 41,j-VI -� -- -