Bacon, Francis TOWN OF Q UEENS B UR Y
Pine View Cemetery niid Cremntorilllll
21 Qi<nker Road, Qieenshury, NY. 12804.5902
(518) 745-4476 (518) 7 4 5-4 4 7 7
http iiw%vw queensbury net
Funeral Director: AA T3 A,
Name of Deceased:Vt qCA, l 1
Case Number:
Date of Cremation: �Lj� '�'f/ j
Retort:
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Time Cremation Started: 2 C) �•��
Time Cremation Completed:
Type of Container: -Ao'` U"OL)+
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Remarks:
CG45G� �, I'+
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" Home of Nnturnl Benuty ... A Cooit PInc , to Liu :
TOE OF QUSSBSBOR!
PINS Ival CWUMM '1
q�gyATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
pRIZ►TIOK TO CRZMAM
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
f r ►�5 F. M I-e.
(Name) (sex)
qq
(Street) (City) (State) (Zip Code)
who died on
day of
at
(Place) ( ess)
Name and address of nearest living relative or name of person
authorizing cremation:
Ce z
(Same) (Address)
Relationship to the deceased wi-Fic
, � -dD
Name of Funeral Home ����� •�••�� M� - �
EMRTANT:
I repre
sent that to the best of my knowledger the deceasdd� as or
has no pacemaker in his or her body. (Circle One to arrange
I certify that I have the full power and authorization ge
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 Crematoriuu from any and all demands
and
demands for loss or damages which may be made again t l th y
f said remains as
reason of or connected such claims o= Dare or are notwho
directed, whether
groan a s, false r fraudulent.
(Witness)
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s
(glgnaty a 07 or Legal Rep. and Address)
Signed on this date:
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