Green, Evelyn 4:2L TOWN OF QUEENSBURY
Pine Vteto Cemetery and Cremntorium
21 Qtrnker Rond, Queensbury, NY. 12804-5902
(S 18) 745-4476 (518) 745-4477
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Funeral Director: I=lys Nlf)
Name of Deceased: �� /=
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Case Number:
Date of Cremation:
Retort: U-)
Time Cremation Started:
Time Cremation Completed: a _
Type of Container:G A\—zo 13���� �(/� ,,�� 11 30101
Remarks: i
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" Home of Nnlurnl Benuty ... A Good PInce to Live "
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TOWN OF QUEENSSURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12604
Phone (516) 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 : _
if C �LJ f'ee.ti- G a �--
(N ■ ) (Sex)
(Street ) (City) (t tate ) (Zip Code )
�\
who died on '�" day of �J� °2aa S�
at Ii d s -- f s
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(Place)U (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
( me ) (Address)
Relationship to the deceased �GC �
Name of Funeral Home K mar
IMPORTANT:
I represent that to the best of my knowledge, the deceased has. or
14 no pacemak .it: his or her body. (Circle 4fte) ,
I certify that I have the full power and authorization to a►wrange
for the cremation of the remains and to direct',tfie disposition of
the cremated remains, that any personal possessions have either
been removed or may be destroyed, and agree ant" protect , defend
and save harmless Pine View Crematorium from v. .and all claims
and demands for loss or damages which may beILmade against them by
reason of or connected with the cremation of said rwma1lbs as
directed, whether such claims or demands are or are not,t4hd,lly
groundless n
o raudulent .
O �C - - L11( �! zt-,�- /0, I
it s > (Address )
y gnature of Relative -or'Legal Rep. /and Address)
Signed on this date : k