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Liburdi, Shirley (roRN OF QUEEVBUr�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 1<�� Name cc ° ` J� t'�'e� j 1^ ��t Case# Date Of Cremation Time Cremation Started Time Cremation Completed Type of Container C'14b 0 tj Remarks k:/` �jl n U � t/1'1 h n Y1 r>!� .4 M M© U!E 1o : 30 n121 tit 0 a - �I �f o� n !l �` �S to Y•-� - TOWN OF QUEENSBURY PINE VIEW CEMETERY 8 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: � �A-eq L���c (NA ) (SEX) (STREET)— (CITY) (STATE) (ZIP CODE) who died on day of _ 20.C)� at (PLACE) (ADDR SS) Name and address of nearest living relative or name of person authorizing cremation: Relationship to deceasedC v� Name of Funeral Home_[ f�l,-eccd fame r IMPORTANT I represent that to the best of my knowledge, the deceased has oGK—a n cemaker in his or her body. (CIRCLE ONE) � J I certify that I have the full power and authorization to arrange for the cremation of the remoher bs and to direct the disposition of the cremated remains, that any personal Posse ions have eiteen. removed or may be destroyed, and agree to protect. defend and save : ..s Pine View,Crematorium from any and all claims and demands for loss or damage , , against them by reason of dr connected with the cremation of sai rem : such claims or demands are or are not wholly groundless, false (WITNESS) (A RESS) Y. . .,:. (SIGN TU E OF R LATIVE OR LEGAL REP. AND RESS) Signed on this date: OC�a„e r