Deed, Eleanor OF QUEE-rAQBUQy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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ate 0f Cremation ,Q - 'L�= -C&
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FROM Saugerties/Woodstoek KOR FAX NO. : 914 247 967.3 Oct. 20 2003 09:44RM P1
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TOWN OF QUEENSBURY
PINE ViEW CEMETERY&CREMATORIUM
ducker Road.Oueensbury,rver►York, 12804
Phone(518)Crematorium 7454477 of no Answer Cembtsry 745.4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, In Accordance with and subject to its
RWss and Regulation to 'ramaste the remains o6:
Z�i _ e
(Name) (Sex)
-(Street) (City) (state) (Zip)
who died on r, 4[ day ofal-
f
(Place) (Address)
Name and address of nearest relative or name of person Authortiring crematon:
.d elti(A&, �g, F
(Name) (Address)
Relationship to the deceased --d
Name of Funeral Home Q
IMPORTANT:
1.represent that to the best of my knowledgq,the deceased has or has no paosmaKer In his or her body.
(Circle One)
I 90r0ty that I have Me full power And autmanimn W fige For the cremation of the remains aid tc
direct the disposition of the cremated remains, that any personal pomselons have elther been removed
or may be destroyed. and agme to proteor, defend and save haarm"s line View Crematorium,from any
aAd ail clslms and demannds for loss or damages which may be made against them by reason of or
eon with the orern ation of acid remains as directed, whslher such claims or demands are or are not
I yodlq7 false or ha lent.
(IMI#ness) (Address)
(Signature of Relative or Legal Rep.and Address))
Signed on this date: % r