Trempe, James v
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rl'ouN OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 1%� CIaC 1J�/ Case# ✓� 4
Date Of Cremation
Time Cremation Started ,'7 0 v•!�'
Time Cremation Completed 1 �j� *vt
Type of Container
Remarks �
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY&CREMATORIUM
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 Or
Rules and Regulations to Cremate the remains of:
J times CeNop-
(Name) (Sex)
04&y\ 1�r rt, k
(Street) (City) J (State) (zip)
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who died o day of yl • 20 65'
at �� Q,`Q,lil 1!� tV� �• ��D
(Place) (Address) i
Name and address of nearest relative or name of person Authorizing cremation:
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(Name) (Address)
Relationship to the deceased
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Name of Funeral Home 1AAA
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IMPORTANT: = '
I represent that to the best of my knowledge, the deceased has or has no pak f :hio br her body.
(Circle One) '
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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 p ossessigns have either been removed
or may be destroyed, and agree to protect, defend and save harmless Pill iew Crematorium from any
and all claims and demands for loss or damages which may be made_, ainst them by reason of or
conn cted with the cremation of said remains as directed, whether such cl or demands ere or are not
w I ground[es false or fraudulent.
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(Witne )
Add ss)
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Zota;4L
( ignature of R Iaftive or Legal Rep. and Address))
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Signed on this date: 0 Z - I
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