Derecskey, Charles r
. ""RN OF QUEEM
,5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENI SBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
=uneral Director
Name �,��j �,� s ,�� Case # �
Date or Cremation
Time Cremation Started
Time Cremation Comole-ed �� vl—d
Type of Container -/,e'ti�f,7 chbk�E1
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: _
� P .
r P i/�
(Name) ( Sex)
bze
( Street) J (city) ( State) ( Zip Code)
who died on �� day of c re/G ."'�7 I-etf �ell�
at �N i� 1AVJ-1e1AVT ` d✓ /C
(Place) (Address ) ir
Name and address of nearest living relative or name of person
authorizing cremation:
�- !/. o/y Ar-1'P e
(Name) (Address )
Relationship to the deceased k>1
Name of Funeral Home
IMPORTANT: "
I represent that to the best of my knowledge, the deceased-lias br
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct the disposition -of
the cremated remains, that any personal possessions have eithler
been removed or may be destroyed, and agree to protect, defend and
save harmless Pine View Crematorium from any and all- claims and
demands for loss or damages which may be made against them by
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 )
( Signature of lelative or Legal Rep. and Address)
Signed on this date: 1 �