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Girsdansky, Michael rl-oWN of QUEENs5BURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director �� C,j, x i tic f Name Case # Date of Cremation O-L, Time Cremation Started 4 f J16 i9 /M Time Cremation Completed t M I Type of Container 6AR,997hl l 45 /t C. •�©� ��Y Remarks : ' / File /M APR-10-02 05 : 17 PM CLARK FUNERAL HOME 5185233338 P. 02 TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM 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 wit and subject to its Rules and Regulations to cremate the remains of MICIIAEL 'S. GIRSDANSKY a h (NAMS) .% (SEX) 30 Greenwood Street, Lace P14210, NY 12946 _,,...�,.... (STREET) ( ITY) (STATE) (ZIP CODI i} who died on l 0 t it day of at Adr ".G Medical Center Saran-aig—Lako, my (PLACE) (ADDRESS), Name and address of nearest living relative or name of person authorizing crematio!!: Mr. Pail Girsdans►c Relationship to deceased Son .�.�. Name of Funeral Home N. R. Clar%, inc.27 Saranac Ava. . T.:-'c' id, NY 12946 IMPORTANT I represent that to the best of my knowledge, the deceased h_yt ofWU rrpacemakor in his or her body. (CIRCLE ONE) I certify that I have the half power and authorization to arrange for the cremation of tl to remains and to direct the disposition of the cremated remains,that any personal possessions he-to either been removed or may be destroyed, and agree to protect,defend and save harmless Pin v 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 a or are not wholly groundless,►alse or fraudulent.. / � 5-%1 7✓�� "7`�"LS C CU 1 je'f WITNESS) (ADDRESS) { NATURE Or 101911 REP.AND ADDRESS) 2 C' Signed on this date: n�,* rj 1 ing? -