Chandler, Harry rrO`L1 = QUEENB U99 Y
PINE VIE "'.'ERY AND CREMATORIUM
QUAKER J rNSBURY, NEW YORK 12804
1 76 (518) 745-4477
3 [ ;rector jjJj A10 rz
Name /- 0RRj _ _ Case # C/ 7
Date of Cremation_ — f<� — 2d0
Time Cremation S-.art 1 !j �/✓l
Time Cremation C,)mp_
Type of Containe yq .} 1�-�� �(V1 1�—S 1 �\j a U _VA,
Remarks : AM
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TOWN OF QUEENSBURY q7�
PINE VIEW CEMETERY
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CREMATORIUM
Quaker Road, Queensoury, New York 12804
Phone (518) Crematorium 745-4477 (if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject
to its Rules and Regulations to cremate the remains of:
(NA ) (SEX)
(STR T) (CITY) (STATE) (ZIP CODE)
who died on
day of ALAS 20 0 zJ
at J
(PLACE) (ADD ESS)
Name and address of nearest living relative or name of person authorizing cremation
Sv, "I -_ C—ka�
1
Relationship to deceased_ 4J•;
Name of Funeral Home r
IMPORTANT
I represent that to the best of my knowledge, the deceased has o
body. (CIRCLE ONE) bias no pacemake in his or her
�_.
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 claims or demans are or re not wholl groundless, false or fraudulent.
( SS) / (ADDR S)
GI�G� 6--y�—e_ h
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: `—