Lopez, Marcia (-rO WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ti
Name HCA" 1 , LOP Cz Case# Ll 1
Date Of Cremation
Time Cremation Started ' S T /. H _
Time Cremation Completed (O: A
Type of Container C�rAuclrC{ Cr�,wrord lSfi C'C'.�
Remarks
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OWN OF QUEENSBURY
•• PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury. New York 12804
Phone (518) Crematorium 745-4477 (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:
1"klc -C\a olpP 7
(NAME) (SEX)
0 2\per
(STREET) (CITY) (STATE) (ZIP CODE)
who died on d('. V)f'� day of 20 U
at
(PLACE) (ADDRESS)
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Name and address of nearest living relative or name of person authorizing cremation:
��rY1aS Lt,1P-a 9?L -e r r�
Relationship to deceased
Name of Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased hasbr halm pacernakef in his ocher
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of this 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 all 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
su clai s or demands are or are not wholly groundless, false or fraudulent.
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( IT (ADDRESS) 4
(SIGNATURE OF R
RE
P. AND ADDRESS) �",• .
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Signed on this date:
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