Dickinson, Harold Funeral Director:
Name of Deceased:
Case Number:
Date of Cremation: (Ie
Retort: C J;Z ALJ-T—dt2U
Time Cremation Started:
Time Cremation Completed:
Type of Container: [�Y`� C �1- r/-� \-� j 2`,10
Remarks:
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00/07/2005 C8:58 FAX 41074742UL Jikf bK ANll -V-JVvi
05/05/2005 15:14 513-''y2-12> ? REUN&DENNY h1Z46 �f ��j FAGE @_
TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Rlosd,Queensbury,Now York, 12804
Phone(518)!Crematoriurn 746.4477 of no arnswer Cemetery 745.447E
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, In Accordance with and subject to its
Rules and Regulation*to Cremate the remains of.
a cb�d �OK nSDr \ --
(Name) ;Sox)
(Street) (City) (State) — (zip)
who died on f~� day of -Tune— 2oQ!5IMAM
r
(Place) (Address)
Names and address of nearest miatwe or name of person Authorizing cremation.
(Name) (Address)
Relationship to the deceased I
i
Name of Funeral Horne n
IMPORTANT:
j
(,*Present that to the best of my knowledge,the deceased has or as n pacemaker in his or her body
(Circle One)
i certify that 1 have the full power and authorization to orrange For the crernastdan of tree remains and to
rlireCt the dlapositlon of the cremated remains, that any personal possesaionz,have either been removed
or may be destroyed,and raga v to protect, defend and save hermiess Pine View Crernatoriurn frorn any
and all claims and demands for loss or damages which many be made,agalnet them by reason of or
connected with the mmadon of said remains as diremd, whether Wch claims or demands are or are not
wholprou �Iqs:r or fraartidulent-
(tnr s) (Address)
C�L A fly"_
(Signature of Relative or Legal Rep. and Address))
Signed on this date
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JUN-6-E00' 06:31 FR011:H0LICR( INN EXPRESS L604121100 T0:151879 12E7 t'7�Lt NGY
06/06/2B@5 06:34 510-792-1287 ��MDLNW �1' 4�'
TOWN OF QUEENSSURY
PINE MEW CEMETERY&CREMATORIt
Quaker Rand,Oueeashury,New York,12" 746.4475
phone(816)Cramatottum 745-1477 of no aus�00
OY
AUTHORIZATION TO CREMATE: l
The undersigned"nuasts and auftftn FNrre View Crorniaatorium, in AoOibrdsnca With and sutpct to ita
Rubs and Regulauons m Cramata the m"slns Of,
:.»e t
(Name) ( )
it
(gam} (City) (State} (Zip)
day
2 �,d of
who died on
(per) (Addr+ess)
Name and addrem f r mreg relative or name of parson Audwrizing crw stion.
e
(
ReIvIlonahip b the dw eaaad
Name of FufmW Horne
r
IMPORTANT: �
oast to tl>le best of my kno'w� as 9a,the(190MIed h Aker in his or her body- j
(Gods One} d
I
I o that I have the full power and authori�tion to arrange Fort the clefs UW of the ternalns and to
ettlry
diret the disposition of the a8mstbd kw,vW my p p �how elther been removed
or may be destroyed, and agn"to protean,defand and save hwmlmw PieView Cmrrawrkrm fmm any
rend all claims and demands for iM or damages which may bs mAd�against them by mom of ur
oorinemdvAt+the Of Bald ru ankle as dlraat d,whow swh cfglms or derrrands We Or an rrut
wholly gro E ,fa r uduWd,
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(Signature of Relative at taper R*p-and Address))
Signed on this date:
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