Adamson, Charles �o OF QUEEN,5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �V14 t—(
Name � l� K � S � C/ � C a s e#
Date Of Cremation � ,F--
Time Cremation Started 3 !!�L`
Time Cremation Completed
Type of Container
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Remarks
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TOWN OF QUEENSBURY
P , VIEW CEMETERY&CREMATORIUM
0 Qu r Road, Queensbury, New York, 12804
�.1 h11"' )C s torium 745-4477 of no answer Cemetery 745-4476
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THORIZATION TO CREMATE
The undersigned 'iw a es Pine View Crematorium, in Accordance with and subject to its
Rules and Regulations to Crema remains of:
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+� Ltdr)C.� uY�?s M0-Le
(Name) (Sex)
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(Street) »`� (City) (State) (Zip)
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who died bn day ofat. 2J
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(Place) : (Addy s)
Name and address of nearest relative or name of person Authorizing cremation:
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(Natne:) I (Address)
Relationship to th � sed w�
•Narhe of Ft e
IMPORTANT.,
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I represent that to the best of my knowledge, the deceased has o has no pacemaker in his or her body.
(Circle One)
I that I have the full power and authorization to arrange For the cremation of the remains and to
e disposition of the cremated remains, that any personal possessions have either been removed
be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any
WI 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 gro dies s fals raudulent.
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Wiitn s) (Address)
(mil L V-- /3- Oalxlr���
(Signature of Relative or Legal Rep. and Address))
Signed on this date: