Buban, Thomas TOWN OF QUEENSBURY
Pine View Cemetery nnrl Crematorium
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745-4476 (518) 745.4477
http //w%v%v.queensbury net
Funeral Director:
Name of Deceased: �r'T C� Gj lJ (3
Case Number: L q
Date of Cremation: l—)
Retort: C�R A L 1�G�2— C/
Time Cremation Started:
Time Cremation Completed: ' �, r2—-Lj
Type of Container:
Remarks:
i
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
Rules and Regulations to Cremate the remains of:
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(Name) n� 1 ('� (Sex) �1 I -S j j' �� 1 L C1 C i l,( V Gc; ")>iJ`) )r\ u
(Street) (City) ( tate) (zip) ,
who died on 7 day of 20 0-'
at > �
(Place) (Address
Name and address of nearest relative or name of person Authorizing cremation:
(Name) (Address) .
Relationship to the deceased
r
Name of Funeral Home
r
IMPORTANT: ` ft"- 4
I represent that to the best of my knowledge, the deceased has oEs no pa ram" i 4 her body.
(Circle One
I certify that I have the full power and authorization to arrange For the cremation of the iemains 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 CrAnatodum from any
and ail claims and demands for loss or damages which may be made against them by reasbn,of or
connected with the cremation of said remains as directed, whether susP claims or demands are*are not
wholly groundless, false or fraudulent.
(Witne (Address)
(Signat re of Relative or Legal Rep. and Address))
Signed on this date: ',