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Smith, Clara a TOWN OF QUEENSBURY Pille Virtu Cemetery nod Crentntnnuin 21 Qunker Rond. Qieenshnry, NY. 12804.5902 (518) 745.4476 1518) 745.4477 http iiw%v\v qucensbury net Funeral Director: (fie r Name of Deceased: Case Number: M Date of Cremation: A4- Retort: Crr,"'4-� Time Cremation Started: 1 . V 15, Y� Time Cremation Completed: '��2 1- Type of Container: C5 rd &11' Remarks: to a! oo Cj M o f Pkj PM Hjitc 0 / nt .trn1 8enuly . R Cnnd PInie In Ltue TOWN OF QUEENSBURY 39c;l 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: (Name) (Sex) S iLV4111, ?.'01 rJ F- A)� (Street) (City) (State) (Zip Code) who died on q " day ofLti - D�S at (Place) (Addre s) Name and address of nearest living relative or name of person authorizing cremation: ._NCam, kod wnonrf (PS' 50rnc S� . PCOF= 1�— (Name) (Address) `� Relationship to the deceased dzgadn2 L/ Name of Funeral Home 2 h 4 VA .0 IMPORTANT: I represent that to the best of my knowledge, the deceased has or 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 posse s�' .�ons have either been removed or may be destroyed, and agree to pfotect, 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 connected with the cremation of said remains as directed, whether such claims or demands are or are not wholly groundless, false or fraudulent. ( . itness) (Address) (Sitnature of Relative or Legal Rep. and Address) Signed on this date: 3 - -;�6©3'