DePaul, Eleanor . ' rnq+N OF QUEEN
,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorXc (f,4, a&d /
Name 11. 6 oR Case
Date of Cremation
Time Cremation Started &,`3 &M r
Time Cremation Comoleted
Type cf Container �110) 7/1V6— co)V / 31 n, cAS
Remarks :
l/ J& /M
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7 6r; 17'J' 1� �,jR-14' -d47i r 0G'!�ctl'_Liit;,
(TOWN OF OUEENSSURY
PINE VIEW 'tf
CEMETER
&
CPEMATORIUNI
Quaker ad, Queensbury, New York 12804
Phone one
8�C ematoriurn 745.4477 (it no answer)
Cemetery 745-4476
AUtHORII-ATION TO CREMATE,
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The undersigned requests and authi fizes Pine View Crematorium, in accordance will)and
subject to its Ruies and Regulation to cremate the remains of.
(NAME) SFx)
pf701��-
(STPEET) (CI (STATF) (ZIP CODE)
who died on day of�_ _
at - ../`- -I}PRIES
44/A
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Name and address of nearest living�elative or name of person euthoriz!ng cremation:
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Relationship to deceased I -----
Name of Funeral Horne
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IMPORTANT
I represent that to the best of my kin ✓,�iedge, the decrased liras or tnq pacemaker in his or tier
body. (URCt_E ONE)
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I certify that I have the full power an autru.,rizaban to arrange trnr the Cremation of the remains
and to direct the disc)osition of tl)e crprn.Med remains, that any per?anal}possessions have either
been removed or r710+be destroyed. and agree to protect,defend and savA harmless Pine VieA
Crernatoriurn firm 8ny and all clalni and demands for loss or aa.rrages which m ay be made
agains!them by reason or or connected with the cremation of said rernains ps directed.«t;elher
such GI- s o► dr,n1ar)ds are or are riot wholly groundless,faise or fraucrulent.
(WITNESS) (A L%RE5S)
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(SIGNATUR OF4REATjv: OR L :GAL REP.AND Ai7Uf7FSS)
Signed oft this date.�JL�`�` f!
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