Loading...
Dinger, William rro 7+N OF QUEENB URY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, -NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Rj ;r NameCase # Date or Cremation Time Cremation Started /x d/ M I Time Cremation Completed ?c oZ, Type of Container Remarks : 6-- 1l%f© "'q�ly'� ' ':.$:'t*-�; , "'�' z+S;�"$, '�tr,,,,±g�;jj� r,":,.ra-- 1, N - . . •1. _•..z• >"3r4} �` .;' - rt•T dapp'&- 4 k ,7%!<ypz�'{ �t P'ia.,Ez*2,V gt.,i "'3 t S N 2 1'by,-S -I 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 AUTHORISATION TO CREMATE The undersigned requests and authorizes Pine View Crematorium, in.f .-` accordance 'with and subject"to its Rules and Regulations to cremate the remains of: w , (Name) (Sex) (Street / (C ty) ('State) (Zip Code) who died on lO day of _ Vf 7at �dOf 3 12 (Place) (AddpKss) ' Name and address ofnearest_ living relative or name of personw.: `3. authorize cremation• '' r ' 4r� . •-(Name), (A ,, ' Relationship to.the7deceased Name of Funeral'.Home " *' r j; IMPORTANTs I represent that to the _best of my knowledge, the deceased hasp=or, has no pacemaker in his , or, hem; bev y. ,� (Circle One) rt Y I certify that I have the full power and authorization to arra ge , ,. for the cremation of the remains and to direct the disposition' of 'M,; 'the cremated 3�remains, that=`zany personal possessions ,.have ..'either' ' "been removed or may be destroyed,- and agree to protect', defend''and4 save harmless Pine View�Crematorium from any and all claims*-and;; demands for loss or damages which may be made against them reason of or connected with ' the. cremation of said remains as .: <: directed, whether such claims or demands are or are not wholly gr dless, false fraudulent.- ,. :a t , 10 mot- (LA Al) N Q- 3,� (wit ss) „(Address) �....� (Signatu a of Relative o sgal Rep. and Address) Signed on this date: 0