Lawton, Ruth t `
r-rO rW N OF QU-E E N,5 B 2.1-R,,.y
PINE VIEW CEMETER'r AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
Funeral Director
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04/30/2004 09:36 518-745-4445 TOO COMPTROLLER PAGE 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, 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:
wfiti E, L
(NAME) (SEX)
(STREET) (CITY) (STATE) (ZIP CODE)
who died on
day of /G rl 200S
at �G h lfc /O✓!av/A9-
(PLACE) (ADDRESS)
Name and address of nearest tiving relative or name of person authorizing cremation:
don h Z, t�hi✓��.,
v
Relationship to deceased
Name of Funeral Home
IMPORTANT pacemaker In his or her
I represent that to the best of my knowledge, the deceased hM or has no p
body. (CIRCLE ONE)
I certify that t 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 demands are or are not wholly groundless, false or fraudulent.
( ESS) (ADDRESS)
(SIGNATUFM OF LATIVE O• GAL REP. AND ADDRESS)
Signed on this date:
04/30/2004 09:36 518-745-4445 TOQ COMPTROLLER PANE 01
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, 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/cremat :
,e the remains of
/l
(NAME) (S )
-(MEET) (CITY)
(STATE) (ZIP CODE)
who died on
-/4 day of
at IG YJ A0 /D►? i Gti,
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation_
Relationship to deceased
Name of Funeral Home /Yo 6CS �� <�•
IMPORTANT pacemaker in his or her
I represent that to the best of my knowledge, the deceased hu or has no p
body. (CIRCLE ONE)
1 certify►that t have the full power and authorization to arrange for the cremation of the remains and
to dlr6ct 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
m Creatorium 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 deman)b are or are not wholly groundless, false or fraudulent.
�y ve. �wff os
( ESS) (ADDRESS)
(Si _U O LATIVE O
GAL REP. AND ADDRESS)
Signed on this data: O/ 7 "OS