Beebe, Gary TOWN OF QUEENSBURY
Pine View Cemetery nod Cremn tort ufit
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745-4476 (518) 745.4477
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Funeral Director: ►,V �- � --I-, -P,5C-Wfk
Name of Deceased: ('�- ��- 1'—E )Q V/
Case Number: S L4
Date of Cremation:
Retort: ��
Time Cremation Started:
Time Cremation Completed: K 'w
Type of Container: Ci1l"Q, -,-� 14 v IJ r � 5�)
Remarks:
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12004
Phone(516)Crematorium 7454477(if no answe►)
Cemetery 745A4.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance Willi and subject
to Its Rules and Regulations to cremate the remains of.
Gary H. Beebe Male
(NAME) -
(SEX)
43 Outlet Drive Ticonderoga, New York 12883
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 1 9th day of February 20 05
at his residence - 43 Outlet Drive, Ticonderoga, NY 12883
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
F. Michael S. Martin, P.O, box 60, Whitehall, New York 12887
Relationship to deceased
Name of Funeral Home Wilcox & Regan funeral home, 11 Algonkin St.
Ticonderoga, New Yor
IMPORTANT
I represent that to the hest of my knowledge, [lie deceased bas or haum pacemaker in his or leer
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for(lie cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be deslmyedi and agree to protect,defend and save harmless Pine View
,Crematorium from any and all dalms 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.
(WITNES (A -SS)
(SI R RE TI R LE DAD -
Signed on this dale:_
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