Lofgren, Carl TOTS OF QUEE9 50 21T7y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
a7re C,�w- Case#
_ate Of Cremation JJ-- >O - -L'co'
T :me Cremation Started CZ /-) ,
' ime Cremation Completed
'Vp e of Container -�30Ay)-y
Kemarks
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NOV-07-2003 14:46 Mulligan RE 608 833 0288 F.02 -7
_k !TOWN-OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORtUM
Quaker Road,Queensbury,New York, 12804
Phone(518)Crematorium 745-4477 of no answer Cemetery 745-4478
AUTHORIZATION TO CREMATE
The undersigned r%pests and authorizes Pine Mow Crematorium, in Accordance with and subject to Its
Rules and Regulations to Cremate the remains of,,
(Name) (Sex)
(Street) (City) (State) (Zlp)
who died on _ . 6� day of lVgy 20 a3
( .." Y?'L=car
place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:
(Nwn (Address) 3 0
Relationship to the deceased
Name of Funeral
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 1 have the full power and authorization to arrange For the cremation of the remains and to
direct the disposlilon 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 lass or damages which may be made against them by reason of or .
connected with the oremation of said remains as directed,whether such daims or demands are or are not
kvb"ndiess,fal r fraudulent.
229 t
TLA-60A( n s) (Address) Io
Aodr.% .
{ ignatur of Relative o gal Rep. ans))F.
Signed on this date' W -7 Jd-3