Minges, Ardys OF QUEEN,5BUP�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR'BODY PURSUANT TO NEW YORK STATE PUBLIC
r HEALTH LAW SECTION 4145(2)(B)
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1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL—TRANSIT PERMIT
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2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
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4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. NAME OF PERSON IN CHARGE OF CEMETERY
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6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
• TOWN 01= OUL=ENSBURY
Plol ylQ;6W CEMETERY
4 CREMATORIUM
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Quaker Road. Queensbuiy. New York 1213U4
Phone t5la) Crefnatofium 745-4477 (if no answer)
Cemetery 745-4476
AUTI IOIZIZAI-ION 1 O CREMAl E
J The undersigned requests and aullmizes fine View Gae"nalununi, in accuidance with and subject
to its Rules and Regulations to cienfate life ienfains ul:
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(NAM (SEA)
(STREET) (CITY) (S1'A1 =) (ZIP CODE)
« who died on day of 20
at
(PLACE) (AD RESS)
Name and address of nearest living relative or name of person authorizing cremation:
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Relationship to deceased .
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has leas Il pacemaker In his or her ,
body. (CIRCLE ONE)
I certify that I have the full power and authorizaliolr to arraliye 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
su,cb claims or de ds are or are not wholly groundless, false or fraudulent.
ESS) (AD RESS)
IGNATURE OF RE TIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: / 143