Peters, Mary I o��� of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �i'roc, , f=}-61.4 `l
Name ( �1==� Case #
Date of Cremation �,, — 2 `fir- 7z-00
Time Cremation Started s 1°T/Y\
Time Cremation Completed
Type of Container <�wA'
Remarks : 1
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TOWN OF DUI=-ENSUUItY
PINE VIEW CEMETERY
3. -
CREMATORIUM
Quaker Road. Queeirsbuiy. New Yuik 12UU4
Phone t510) Crenioluiium 7,15-4477 tit nu answer)
Cemetery 745-4,170
AUT'I-IOIZILA'I ION '1 O C HEMA I L
The undersigned requests and authurizes Iiiise Viuw Giemutuimm. iii accuidance with and subject
to its Ies and Re Iations to ciemale the ieiriains ul:
(NA E) (SLX)
(STREET) (CITY) (S I A I U) (ZIP ODE)
who died on f day ofat eP to
20
(PLACE) (AD =SS)
Nam and address of nearest living relative or name of person authorizing cremation:
Relationship to deceased C
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has or lias no pacemaker In his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arranye lot 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, delelld 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 laims r demands are or 7ar not wholl gr undiess, false yr fraudulent.IL �� Ire
(WITN SS (A RESS)
(SIG ELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this dale: