Povie, Orrie TOWN OF QUEENSBURY
Pine Vietu Cemetery nod Creinntor ill
21 Qitnker Ronr1, Queenshury, NY. 12804-5902
(518) 745.4476 (518) 745.4477
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Funeral Director: 11:
Name of Deceased: PO Ll
Case Number: i
Date of Cremation: _ _
Retort: — -
Time Cremation Started:
Time Cremation Completed:
Type of Container:
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Remarks:
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TOWN OF QUEENSBURY 6
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road. Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
Orrie Povie Female
(NAME) (SEX)
PVI State Rte . 40 Argyle NY 12809
(STREET) (CITY) (STATE) (ZIP CODE)
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who died on 16th day of July 2005
at PVI State Rte . 40, Argyle , NY
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
Joan Durett
Relationship to deceased Friend
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Name of Funeral Home M. B. Kilmer Funeral Home
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IMPORTANT
I represent that to the best of my knowledge, the deceased Igor has no pacemaker in 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 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 conn led with the cremation of said remains as directed, whether
su=nd`se o not wholly groundless, false or fraudulent.
(WI ESS
(ADDRESS)
IGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
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