Shattuck, Frederick i w
rro+N OF QUEEM5BU'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :v'EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �, /�p/✓��,
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Date or Cremation
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Time Cremation Started ^ rM r
Time Cremation Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM � ct7
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 17 day of e 20 b
at —1 I l A f w,--' lie <'.
-Ink A
(PLACE) (AD RESS)
Name
/and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased C-1 f
Name of Funeral Home 2�-a 6'1 moo^ orL
IMPORTANT
I represent that to the best of my knowledge, the deceased has o na�cemak.ey$or her
body. (CIRCLE ONE) e�
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,eitf er been
removed or may be destroyed, and agree to protect, defend and save harmless Pine Yigvar,;
Crematorium from any and all claims and demands for loss or damages which,may-,,.Pe �ade
against them by reason of or connected with the cremation of said remains as di,regt4pd, whether
such claims or demands are or are not wholly groundless, false or fraudulent. =
ITNES8) (ADDRESS)
Zo aax� JLIt'-
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(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: A- D Do
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