Ford, Ruth (-rnq+N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director jjWSJ
Name F�F- CaseTM
_Date Of Cremation - - 20a �?7
Time Cremation Started
Time Cremation Completed
Type of Container 1Z
Remarks
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07/11/2003 15:14 5186422322
07/11/2009 16:05 5186422322 ROBERT M KING FH PAGE 01
TOWN OF QUEENSBURY
PINE v►l"W CEMETERY
CREMATORIUM
Quaker Road, Queensbury. New York 12504
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersignep requests and authorizes Pine View Crematonum. in accordance with and subject
to its Rules andiRegulations to cremate the remains of:
(NAME (SEX)
p'., "r. V 1XX.�
(STREET) (CI1•Y) (STATEY {ZIP CODE)
who died on ZD
day of - -
at
(PLAC ) (ADDRESS)
Name and address of nearest living relative or name of 0orson authorizing cremation.
ilvi6L-7-Ae
Relationship toldeceasedMA kIL4�
Name of Funerpl Home
t_
IMPORTANT -- no cemaker in his or her
I represent tha44to the best of my knowledge, the deceased hN a,
body. (CIRCLE ONE) `
1 certify that I h ve the full power and authorization to arrange for the cremation of the remains and
to direct the di osition of the cremated remains, that any personal possessions have either been
r or be destroyed,and agree to protect, defend and save harmless Pine View
emOved oy
Crematorium frbm 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
suc AVs or Cemands are or are not whoi!y groundless, false or fraudulent.
(WITH SS) ( ORE S)
(SIG TUBE OF RE TIVE OR LE AL REP. AND ADDRESS)
Signed on this date,
1-2, ( ki
l So
(-, o1 � � I
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