Smith, Walter . rl-nWN OF QUEEN5BURA'
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director !`� �
Name k) 6k—r)�l\ Case # 9 '�
Date of Cremation.�� oZC7O oZ
Time Cremation Started iJVQ 414INII
Time Cremation Completed
Type of ContainerG�/� �
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
A
CREMATORIUM
Quaker Road, Queensbury, New fork 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned reouests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of:
WALTER WILLIAM SMITH MALE
(Name) ., (SOX)
7 BRADLEY STREET FORT EDWARD NY 12828
(Street ) (City) (State) ( Zip Code)
who died on day of
at GLENS FALLS HOSPITAL -., PARK ST. , GLENS. FALLS, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
FLORENCE S. MALLANEY ROCK Hill - SC
(Name) (Address)
Relationship to the deceased
SISTER
Name of Funeral Home M. B. KILMER FUNERAL HOME
IMPORTANT:
I repr n _..t to the best of my knowledge, the deceased has or
has no pacem 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 wholly
' groundless, false or fraudulent.
Witn s) �-�-b tAddress)
(Signat'ure of Relative or Legal Rep. and Address)
Signed on this dates