Jorgensen, Joan rl-OcwN OF QUEENSBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / 1 G C L& Lk ly
Name op. ' () �(Gj � Case # 7,( 1 1
Date of Cremation 2 _ Z00 L!,
Time Cremation Started r-)
Time Cremation Completed 'I ?'Y
Type of ContainerCg4-12-d ��O-�3\"�C)
Remarks :
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08/23/2000 1.1 0 t,1f_i-r 4^-4,7(µ U __'cc r_n r. -
"7 -7 1
TOWN OF OUEENSSURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker(Road, Queensbury, New York 12804
Phone(5181 Crematorium 745-4477 (if no answer)
C:Pmetery T45-4476
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AUtHORII_ATION TO GREMAT L
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The undersigned requests and authorizes pine View Crematorium, in Accordance will)And
subject to its lures and Regulation to cremate the remains of.
i7,6�-- *IV. erev
(NAME) i (SFX)
(STREET) (CI Y) (STATF) (ZIP CODE)
who died en / day of �O- !Kid - _20at
--�
LACE i (AIJ RESS)
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Name:end address o`nearest living�elative or name of person eulhorizing cremation;
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Relationship to deceased
Name of Funeral
IMPORTANT
I represent that to the best of my kn wiedge, the deceased has o l n acenmker in his or her
body. (CIRCLE ONE)
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I ceriry that I have the full power ani autlrvrizatton to arrange tnr the cremation of the remains
and to Direct the jis!>osition of the cipmMe+d remains, that any perionel aossesslons have either
beer, removed ur rra�be des:royed.lArld agree to prote st, defend afro save harmless Pine View
Crematorium Irclr, arty and all clalrng and demands for loss or da.rrages which may be made
ayalnst them by reaso �. o,or connected with the cremation of said remrainw os directed, wt:elher
such aims or d(Imands are or are,II"A wholly groundless, false or fiaaut!/ulent.
01,
vITNESS) (All CRESS)
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(SIGNATURE O L4T " ' OR Lf_ L RFP. A U ADD�FSS)
Signed on this
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