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Peters, Leon '77-17+N OF QUEEVBU-r�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSgURY NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director ame /�-��� ��A C1Zez, Case; J? Dayte Uf Cremati.on I Time Cremation Started ,0 Cremation Completed 10 Tvpe of Container " Remarks ^ r ' I � i i i i TOWN OF OUL=ENSBURY PINE VIEW CEMETERY CREMATORIUM Quaker Road. Queensbury. New York 12804 Phone 1518) Crematorium 745-4477 (if no answer) Cemetery 745-4476 AUTHORIZATION TO CREMATE The undersigned requests and authorizes Pine View Giematonum. in accordance with and subject to its Rules an ulations to cremate the terrains of. L Q vr1 S (NAME) (SEX) (STREET) (CITY) (S ATE) (ZIP CODE) who died on day of 20 y J 01 (PLACE) (ADDf S) I a e and ss of nearest living relative or name of person authorizing cremation: Relationship to decease2� Name of Funeral Hom; ; - 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 7sucJIa' s de ds are or are not ho lly_g round less, false or fraudulent. (WITNESS) (ADDRESS) PeA ( NATURE OFr� ATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: