DeMarsh, Mary (0%N OF QUEEVBW�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director -g FG,4q N VF1\1�
Name Y� �i5 � 6tj Case#
Date Of Cremation -Z Z�l%
Time Cremation Started TI
Time Cremation Completed
Type of Container (� � M P-d i-4&,i /414i
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Remarks
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TOWN OF QUEENSBURY
r
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 of 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'C'rre)mmate the remains of: 1L
(Name) < (Sex)
(Street) (City) (State) (zip)
who died on �h day of c-z?,,4 G 20 dS
at
(Place) (Addre )
Name and address of nearest relative or name of person Authorizing cremation:
MoL ' Yo7c,.r4 -*
(Name) (Address)
Relationship to the deceased x, k
,cam
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o as no ace aker in his or her body,x
(Circle One)
I certify that I have the full power and authorization to arrange For the cre r
direct the disposition of the cremated remains, that any personal possessi "
or may be destroyed, and agree to protect, defend and save harmless Pfne� fnatonu
and all claims and demands for loss or damages which may be ma aga * IRim by read oY
connected with the cremation of said remains as directed, whether suchims Ot demands are ore,inot
wholly groundless, false fraudulent.
(Wit sss)� / (Address)
(Signature of Relative or Legal Rep. and Address))
Signed on this date: ` -�