Miller, James �O uN OF QUEEVBU!F�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ' k
N a m e a- 4i�el� A4,tN4s- Case#
Date Of Cremation A — -I-
Time Cremation Started L{ O p
Time Cremation Completed � ) l 1 6 ��+
Type of Container (,(/by) 14,
Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with
and subj lect to its Rules and Regulations to cremate the remains of:.
(Name) (Sex)
(Street) (City) (State) (Zip Code)
who died on 72 day of 1111.,ef"d r,- 200 s-
at 61-1:1U:, FALLS
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
�AN� /►?itLL lZ 7 '51411 tJ AA'r /3- C.✓,,L, 1 S Nil : l ljVy
(Name) (Address)
Relationship to the deceased
Name of Funeral Home —Ganleten Funeral Hare Ines—, (
IMPORTANT:
I represent that to the best of my knowledge, the deceased has, or as no
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the crem.4tion
of the remains and to direct the disposition of the cremated remains,fat any,
personal possessions have either been removed or may Ike destroyed, and.agree
to protect, defend and save harmless Pine View Crematorium from any.end 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 not wholly groundless, false or fraudulent.
�yJ�2LL'IUa� �IIAILI2AL MOM Z -+^'L
(Witne l (Address)
(Signature of Relative or Legal Rep. and Address.
Z Z Ze�'�
Signed on this date: -
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