Thew, Daniel rf-O WN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 0 G A k,
Name " 1 L � Case#
Date Of Cremation �, _ (Time Cremation Started 91 5 / A
Time Cremation Completed 4 5
Type of Container}-�c� ,va o (d 3
Remarks
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TOWN OF QUEENSSURY G
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if 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 r, mains of:
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(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on day of �`L"3 S 26bat Alt
3
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Address /
(Name) ( )Relationship to the deceased S) S'T-bvL-
l z k LI&
Name of Funeral Home ��) / �'�- F '`'"n L-
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
he
reasoned f or whethernected with s such claims for demands cremation s
aid remains as
directed, or are not wholly
,
groundless, false or fraudulent.
./ ��
W tness) (Ad s)
ignat of Re atiz
v o Legal Rep. and Address)
Signed on this date: l�L3