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Smith, Edwin a TOWN OF QUEENSBURY Pine View Cemetery nnrl Cremn tort It fit 21 Qunker Rood, Qteenshury, NY. 12804.5902 (518) 745-4476 (518) 745.4477 htrp iiw\v-\v queensbury net Funeral Director: /Y7 1,3h ,rF— 1�-- Name of Deceased: �L.01 % w S✓w t-t' Case Number: r nn v Date of Cremation: ' `6 Ce- 2�J� Retort: (2i(.b4-U) Time Cremation Started: �� C) !4_Az\v Time Cremation Completed: © 4* Type of Container: C',1/ ,\--D 'C,�064-1`TJ r":l,-1 Remarks: Cat i i i r nt :trn1 6eniti A Cnnd PInie to Ltue TOUN OP QU881188QAZ L PINB VIB1� CROMM CitBMATOIiIUK Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 AVIR UTIOff To CSSWAM The undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: (Name) T (sex) r, L-1 (Street) (C ty) 3t te) (Z p Code) who died on �� day Of at (Place) (A dress) Name and address of nearest living relative or name of person a horizing cremation: (Name) ' ( Ae's's) Relationship to the deceased W Name of Funeral Home s INPOItTANT: e resent that to the best of my knowledge, the deceased has or has no pacemaker in his or her body. (Circle One) 9 I certify that I have the full power and authorization to arrange to direct the disposition of for the cremation of the remains and l possessions - the cremated remains, that any persona PO have defend either and been removed Or may be destralreds and agree to protectr save harmless pine vier Crewatorlun frM any and all claims and demands for loss or damages which may be made against them by reason of or connected such claims or demands crematiof or are no remains as directed, whether wholly groundless, false or fraudulent. �� .z 8'� �( tness) A dress) S1 tur o Re at or Legal Rep. and Address) Signed on this date: � -OS