Howard, John TO TI,J7Q OF" QUEEN,5BUP
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i1 Funeral Director �,',�CA-
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De of Container
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TOWN 01: OUEE14SUUIIY j3
PINE VIEW CEMETERY . .
CREMATORIUM
Quaker Road. Queensbuiy, New Yoik 12UU4
Phone t5113) Crenialoiium 7,15-4477 (if no answer)
Ceineleiy 745-4470
AUTHORIZA]ION 'IQ UREMA I E
The undersigned requests and authorizes Dine View Coemalummi. in accuidance with and subject
to its Rules and Regulations to cieniate the remains ul:
(NAME) (SEX)
�abFdOheiye l �s Qs I�8D1
(STREET) (CITY) (S I"A'i E) (ZIP CODE)
who died on day of l'� 20
at -6G� (.f.� e4&eju .
(PLAC ) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased 1,U I C6
Name of Funeral Home f U�'► K1 -1 Irl �Jl
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 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 cl i s or dema d are or are not wholly groun ess, false or fraudulent.
L4L it,
( S) (ADDRESS)
(61GNATURE OF RLqATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: ��