Bieda, Matthew ""MIN OF QUEEVBU-1ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 114 .IN rW� ! _Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed j (p ✓�f
Type of ContainerGH-f---d ���` �f�� j
Remarks
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PIM vim �
CR�TORIdM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
h�BOilI:iTIOB� TO iTS
The undersigned requests and authorizes Pine View Crematorim! in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
(Name)
(Street) (City) (state) fZIP Co e)
who died on 21? day of
at
(place) (Address)
Name and address of nearest living relative name of person
authorizing cremation:
(Name) (Address)
Relationship to the deceased U/
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowled9i'4 ' .eed`his or -
has no pacemaker in his or her body. (Circl
.�,,arrange r
I certify that I have the full poorer and
for the cremation of the remains and to that disposition of
the cremated remains, that any peal Lave .either
been reiamed or may be destra►yed, and agr protectR Mend and
save ham ess Pine View %.Ir vna ftot and all claims and
demands for loss or damages which may be: agai#ft them by
reason of or connected with the crave said remains as
directed, whether such claims or demands or are not wholly
groundless, false or fraudulent.
(Witness) ( esa)
gaature of- Relative or Lega Rep. , 3`
Signed on this date:
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