Burns, Lillian TOWN OF Q UEENS B UR Y
Pine View Cemetery mid Cremn tort uIII
21 Qunker Rond, Queenshtiry, NY. 12804.5902
(518) 745-4476 (518) 745.4477
http Ilw\v\v queensbury net
Funeral Director: -(� � �-� C�(J 1` � ►-- G.-
Name of Deceased:
Case Number: - 7
Date of Cremation: ) -r'006
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container: C t4N-2D 00A C 4 A, 3 0 A-AA
Remarks:
1 C-41a.s = o I Or tic ayt,�� � SOU us,
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Home o/ NntitrnI Bennty ... A Cood Plnce to Live "
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury, New York 12004
Phone(510)Crematorium 7454477(if no answer)
Cemetery 745A4.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crernalorium, in accordance wilh and subject
to its Rules and Regulations to cremate the remains of.
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(NME) (SEX) --
(STREET) (CITY) (STATE (ZIP CODE)
IQ
who died on y day of _ V( a rr 20 S
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at S� .
(PLACE) DRESS)
. T� COndP.r-paQ�
Name and address of nearest living relative or name of person authorizing crema(on: �`11
f rQdo NLy.
Relationship to deceased___/�,� p r
Name of Funeral Home /
awn • nPh� l 'M�
IMPORTANT
1 represent that to the hest of my knowledge, the deceased has gas n pacemaker in his or her
body. (CIRCLE ONE)
I cerlify brat I have the full power and authorization to arrange for the cremation of Hie remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyedi and agree to protect defend and save harmless pine View
,Crematorium from any and all dahns and demands for loss or damages which may be made
against(hem by reason of or connected with the cremation of said remains as directed,whether
such claims or demands are or are not wimny groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date:_