Rowell, Roscoe Jr. TOWN OF QUEENSBURY
Pixie View Cemetery and Cremn tort nm
21 Qinker Rond, Queensbury, NY. 12804-5902
(518) 745.4476 (5I8) 745.4477
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Funeral Director: I ' `' 4 xr/Z! " `
Name of Deceased:
Case Number:
Date of Cremation: C 2 O G SJ
Retort:
Time Cremation Started: ^ 3 0 A-41
Time Cremation Completed: ���✓� �
Type of Container:
Remarks:
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Town or QU$NBSSIIA=
9 PINB VIBK CSNBRS
CRBMATOR110M
Quaker Road, Queensbury, Nov York 12804
Phone (518)- Crematorium 745-4477 or if no answer
Cemetery 745-4476
AtT28MZATXOK TO MANAM
The undersigned requests and authorizes Pine View Crematorium in
accordance with and sub j ect to its Rules and Regulations to cremate
the remains,Af:
(Name)Aun,,00ci,
/J ( ex)
6A-&-. C �
(Street) (City) (�(St�ate (Z p Co e)
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who died on
day of � J 2�
at C — �t'T' / 2�0
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
12 A/07?'( &,,(-4 A-) to62 C/7 4-,'
(Nam (Address)
Relationship to the deceased-.--. �zr
Name of Funeral Home //V-MJ1222:�-
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7A
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I represent that to the best of my knowledge,, the deceasedqas 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 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 such claims or demands are or are not wholly
groan es , false or raudulent.
( nes7),-,
( e s)
(Signature o Relative o Legal Rep. and Address)
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Signed on this Bite: S