Sullivan, Jeremy TOWN OF Q UEENS B UR Y
Pine View Cemetery nml Crenrntoriurn
21 Qttnker Rond, Queensbtiry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp //w\vNv queensbury net
Funeral Director: L c C it i k-\
Name of Deceased: petm �-Iltvsv,
Case Number: 1
Date of Cremation: a 3
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Retort: C rw� Cd
Time Cremation Started: q . i 0 A M .
Time Cremation Completed: l o ; �)o A ,M
Type of Container: L rV i S+
Remarks:
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(TOWN OF QUEENSSURY
r PINE VIEW CEMETERY
&
CREMATORIUM
Quaker tkoad, Queensbury, New York 12804
Phone(516 Crematorium 745-4477 (if no answer)
Cemetery 745-4476
r
AU i HORIZATiON TO CREMATE
The undersigned requests and auftrizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
� iY,4AJ �!
(NAME) (SEX)
a-- # -AW)A!�;Y
(STREET) (CI Y) (STATE) (ZIP CODE)
ff11 I �^
who died on day of � 20Q
at
PLACE i (A (�RSS)
Name rrrd ddreess o`nearest living relative or name of person a~ulhorizing cremation:
Relat?onshio to deceased 14
Funeral .v � ,l c�`y�ce
(Jame of F one Hcm e �
l
IMPORTANT
I represent that to the best of my kn Medge, the deceased teas or has rro pacemaker in his or her
body. (CIRCLE ONE) I
I
I certify that I have the full power en j authorization to arrange trrr the cremation of the remains
and to direct the disposition of the crpmrted remains, that any personal possessions have either
been removed ur may be destroyed. and agree to protect,defend and save harmless Pine Vlow
Crematorium Iran any and all claim and demands for loss or da:rrages which may be made
against them t)y reason o`or connected with the cremation of said remains os directed,whelher
suc c.i ms or d(:ma - are or ar riot wholly groundless,false or
fraudulent-1 ESS) --
t
UFtE OF REt TIVIF OR LEGAL RE .AND ADDRESS)
Signed on
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