Loading...
Welsh, Nancy TOqIN OF QUEE9 5BUJ1 y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4-477 Funer/a1 Director 7XfC_C, Zj='ALA 14 &t.eL7kl Casea Z') r gate Of Cremation T ' Me Cremation Started ' ime Cremation Completed L1 s pe of Container�� }2�f �y�s� � �i=��1 ( U �► V Ke�arks Zc �$/23/ZdE�7 tJ9: e-74E-4474 1 U (TOWN OF OUEENSBURY PINE VIEW CEMETERY & CREMATORIUM Quaker kad, ©ueen3bury, New York 12804 Phone(5181 C.e^iatoriurn 745-4477 (if no answer) Ctmetery T45-4476 I AUtHURIZATION TO GREMAT C i i The undersigned requests and auth razes Pine View Crematorium, in accordance witty and subject to its Fiures and Regulation to cremate the remains of. lV uC V tvg (NFL E) ' (SEX) v%/l .70 (STREET) ((;I l') (STATF) (ZIP CODE) or who died cn_ _ —clay of Y- -4 �6 _f/ J— (PLACE r (AL rRESS) f Warne grid address o`nearest living�elative or name of person eulhoriz!ny cremation: Relationship to deceased / Name of Funeral Hcme cc), &Aj eAJ�[_' IMPORTANT I represent that tc the best of my kn r,-iedge, the beceased h-as has na acemaker in his or her body. (CIRCLE (ENE) I 1 cer;rry that I have the full power drill authurizahon to arrange t�sr the crematrc47 of the rernains and to direct the dis'oosition of the cnrmatod remains, that an/f er?onel possessions have either beer, removed or r,a a be destroyed.Isnd agree to protect, defend wid sa•,e harmless Pine Vie'h Crematorium mein any and all cialml and demands for loss or;ia.riages which may tie made agains!them by reason or or connected with the cremation of said rernains as directed,%khelher such ms or dr-trriands ar ar are pt wholly groundle s,faisa or fi auctulent. jL— WITffes (ACJCRE55) i (- I ,NATU�RFIATI`J: OR L! yL REP. At ADDRESS) Signed on this dale:����—`f�- - — -- I I I