VanDyke, Arthur TOWN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director IA r
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Date Of Cremation Id lb CGS
Time Cremation Started
Time Cremation Completed
Type of Container rAbuhr � 'f7
Remarks
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CRBIlATORIO![
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
A pRIR =GW TO CROO!'1'S
The undersigned requests and authorizes Pine View Crematorium,, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
F•r u R Elisex>
(Name)
mkc x • Z
(St eet) U (City) (State) (Z p Code)
who died on I D '6- O S day of / ^i
1 � �jc•
( ace) ( ess)
Name and address of nearest living relative or name of person
authorizing cremation:
Z r luq z m
(Name) (Address)
Relationship to the deceased n �
a- L./I k
Name of Funeral home
IMPORTANT:
rest- t to the best of my knowledge, the deceased has:or
has no acemaker his or her body. (Circle One) 4} `
I certify that I have the full power and authorisation` to, arrarW
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 destroyedr and agree to protect, defend and
save harmless Pine Ylew Cre�aatoriva from any and all claim and
demands for loss or damages which may be made against by
aid I An
reason ,? or ��such with the crewclaims or demands o are
directed, whether
gro�n ess, false car fraudulent.
7 ► .
4 ,-71P I
es
(Sipature of Relative or Legal Rep. as
Signed on this date: C )