Ryan, Mary rl-nWN OF QUEEN
,5B U9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director VA A-L �✓ �Z-
Name yll!r 1-. Case# 3
Date Of Cremation /6) f - -Z
Time Cremation Started 0 yt.►.-,
Time Cremation Completed
Type G i4 ZZU O"�Zc
T e of Container �
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 7454477 (if 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 CODE)
who died on 13 day of
20 0S-
at -q-k-1 T
(PLACE) (ADDRESS)
am and address f ne rest ' ing tiv r name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home rn, 6
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyed, and agree to protect. defend and save harmless Pine View
Crematorium from any and claims and demands for loss or damages which may be made
against the reason of r c nnected ith th re ation of said remains as directed, whether
such c "ms or demands ar o are no olly o diess, false or fraudulent.
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4 (WITNESS)
(ADDRESS) I
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(SIGNATURE OF RELATIVE OR LEGAL REP. ND ADDRESS) j
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Signed on this date:-D&h / S= 0 S—
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