West, Fenton Funeral Director:
Name of Deceased: +0 I,)
Case Number: 2, � Z—
Date of Cremation:
Retort: C-tkAW '�:u\2-
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Time Cremation Started:
Time Cremation Completed: '1 d
Type of Container: \-56�-�`Z cJ /I�Lv�v� 30 Al-OPI
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Remarks:
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TOWN OF QUEENSBURY Gl
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
•
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
to A/ (a A S - b)Iff, S T
(Name) (Sex)
70 �1a i� ��^ ke (p Bare n
(Street) (City) (State) (Zip Code)
who died on %..yc / day of �.Al
at tf as _Taf
(Place) I (Address)
Name and- address of nearest living relative or name of person
authorizing cremation:
(Name tv (Address)
e hSp
Relationship to the deceased ,�A/`'I f� 4) �
i
Name of 'Funeral Home /�'�lV
IMPORTANT:
f my kno
e resent to that to t best owledge, the deceased has or
has nopacemaker in 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
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
d n rtemaiem by
as
reason of or connected with the cremation of
directed, whether such claims or demands are or are not wholly
soundless, false or fraudulent.
g 1 �• ( 2 gw
Ad
s
(Witness) (Address ) �
(Signatu of Relative or Legal Rep. and Address)
Signed on this date:
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