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Noiseaux, Donna TOWN OF QUEEN,5BU-r�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral DirectorM ,('v6 KF'— %,ame b-'qL)\ Case;` 4139 Date Of Cremation �(�j - � LQ � 2oc i I . .me Cremation Started •c) lime Cremation Completed Q 112� //V\ Tvpe of Conta IZZ6 Remarks 2� Ay\ i TOWN OF QUEENSBURY 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 remains of: JJ©A1A1,4 91 Se g u X (Name) (Sex) (Street) (City) /(State) (Zip Code) who died on day of ©7[o 6 0�- ;2t�a3 at (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: /YjfNct Gr.�#[s'6 - 25'IcPY "//.3�/a %/l�o�g d"�3/'¢iVS'ei�Ba-l, Alfv (Name) (Address) Relationship to the deceased �g /5le_Y Name of Funeral Home IMPORTANT: I represent that to the best of my knowledge, the deceased has or as no acemaker 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. pt4j P- .4 -(/ yAt�f�-- (witness) (Address ) a�L a. oie� (Sid crkature of Relative or Legal Rep. and Address ) Signed on this date: 6