Scurlock, George TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director \ P rg)--'
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Name G, QIZCi 5C-0 9UDC-JX, Case# 35
Date Of Cremation cr u .5'
Time Cremation Started
Time Cremation Completed
Type of Container ( Fa'l( �,' KCX-4lA
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
Quaker Road, Queensbury, New York, 12804
Phone(518)Crematorium 7454477 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 Cremate the remains of:
(Name) (Sex)
(Street) (City) (State) (zip)
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who died on �� day of C 20 0J
at G AJ
(Place) (Address)
Name and address of nearest relative or name of person Authorizing cremation:(Name) (Address)
Relationship to the deceasedc'�
Name of Funeral Home I yn i
IMPORTANT:
I'represent that to the best of my knowledge, the deceased has r has no aCemaker in his or her body.
(Circle One)
I certify that I have the full power and authorization to arrange For the abon of the remains and t
direct the disposition of the cremated remains, that any personal posse ins Aiave either been removed
from or may be destroyed, and agree to protect, defend and save harmless View Crematoriumom any
and all claims and demands for loss or damages which may be made,,against them by repspn of or
cWn
connected with the cremation of said remains as directed, whether su cfaims or demands are or are not
wholly groundless, false or fraudulent.
(Witness) (Address)
ignature of Relative or Legal Rep. and Address)) . ..a
Signed on this date:
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