Daignault, Francis TO'74 OF QUEEN5BU�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 9/d C4
Name �� �� 1 �cllC}'l `r l� ('�� Case# r7—
Date Of Cremation j f — LC ^ Z Z'
Time Cremation Started 3-5- 14
Time Cremation Completed
Type of Container C42d
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM Ll�e
Quaker Road, Queensbury, New York, 12804
Phone(518) Crematorium 745-4477 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 C-r-e-m�aatte the remains of:
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(Name) (Sex)
(Street) (City) (State) (zip)
who died on l day of 20 a
at F )) o, 2"-,4 ). ,.
(Place) (Address)
Name and address of nearest relative for name of person Authorizing cremation: )
' /
(Name) CJ (Address)
Relationship to the deceased
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4,
Name of Funeral Home
IMPORTANT:
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I represent that to the best of my knowledge, the deceased ha or has ncrpa maker in his or her body.
(Circle One)
X..
I certify that I have the full power and authorization to arrange For the creAhtidrLPf the remains and to
ft
direct the disposition of the cremated remains, that any personal possessions-bag 61[her beeh removed
or may be destroyed, and agree to protect, defend and save harmless Pike 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 said remains as directed, whether such claims or demands are or are not
wholly groundless, false or fra lent.
( " ne (Address)
/��Ss)
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( 'gnature of Relative or Legal Rep. and Address))
Signed on this date: X/ay.