Gauger, Donn L V Y V N OF QUEENs5BUry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 9 1Skr74n
Name fkj� ^( �r ()/g�`,�J( Case # 200
Date of Cremation
Time Cremation Started
Time Cremation Comoleted &zd f9 rm ,
Type of Container&A/1�,�',� gt:px,
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of 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:
-On&2 � - G
(Name) (Sex)
/-5' 13 4q ITe T-ae, '� Y
(Street) (City) (St am) (zip)
who died on day of 0J)4 `/ 20C
at HU(y)CC 1 ,� [°f }�h,TU�v X 19 HjG-
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
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(Name) C7 (Address)('
Relationship to the deceased Oj�T 'Q-
Name of Funeral Home ai, -r)� D )r�..�tiuck\ �� � ��
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 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 either 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
wholll roun ess, alse or frau ulent.
VA, da�W,/L e ljto"- T y
Witness) (Address) ipx�
,71 1"i A,I".) / �.,
(Signat of Relative or Le I
Rep. and Address))
Signed on this date: