Derenthal, Bernard C:) -..A TOWN OF QUEENSBURY
Pine View Cemetery and Cremntonum
21 Qunker Rond, Queensbury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http//w\v\v queensbury net
Funeral Director: --�
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Name of Deceased:
Case Number: U
Date of Cremation:
Retort:
Time Cremation Started:
Time Cremation Completed: ( �
Type of Container: !� M% i ~� �
Remarks:
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JUL 03 T3 10:16W '_EBDA P. 1
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road,Queensbury, New York 12804
Phone(516)Crematorium 745-4477(it no answer)
Cemetery 745,4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium.in accordance with and subject
to Eta Rules and Regulations to cremate the remains of
i' je-4�e/7 L#
(SF-X)
&
(STREW (C (STAY (EIP CODE)
who died one day of
at
LACE) (ADDRESS)
Name and address of nearest Ung relative or name of person authorizing cremation:
Gt 1A
Relationship to deceased _ Ll ;4-
Name of Funeral Nome
IMPORTANT
I represent that to the best of my knowledge,the deceased jn or has nc pacemaker in his or her
body. (CIRCLE ONE) e
I oertifjr that I have the fait 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
=ed or may be destroyed.and agree to protect defend and save harmless Pine View
harmlesstorium from any and all claims and demands for loss or damages which may be made
agavA them by reason of or connoted with On cremation of said remains as directed,whether
so i cl ims or demands are or are not wholly groundless,fatse or fraudulent.
(VA ESS) (ADDRESS)
Lz--4'
SIGNATURE O�TIVE OR LEGAL REP.AND ADDRESS �
Signed on this date: -�A//'0 ._
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