Smith, Josephine r .
Funeral Director: / V )<,E \2
Name of Deceased: U�
Case Number:
Date of Cremation: t 5 (•WJ
Retort:
Time Cremation Started: 7r 'Lx b y'►'�'
Time Cremation Completed: 3&
Type of Container: a.O I&W i �✓��y E`I -bor
Remarks:
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1Vm or QUX S URY
PINE VIEW CEMMRY
CR$MATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORISATION TO CRSMATE'
The undersigned requests and authorizes Pine view Crematorium in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
J ®Svi?p ; .Ne
(Name (Sex)
/
(Street) (Cit (State) (Zip Code)
who died on day of Q
at A
AQ
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
?LIZ
Cvm h 5r �'�l/1 -q- 'IazLtmo A d
(Name (Address)
Relationship to the deceased
Name of Funeral Home -A OWK
IMPORTANT:
I }sent t t
the best of my knowledge, the deceased has or
as no pacemaker his or her body. (Circle One)
I certify that I 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 j
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.
- - l ?' - h / S�v
(Witness) O(Address) j
jo
(ngnatAare of Relative or Legal R400. and Address)
Signed on this date: