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Patnode, Irene rl- LO YVN OF QUEEVBU9�Y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 1z �I Funeral Director 13 �— Name 9-Afit�Od r Case# Date Of Cremation t2- © -e:i" Time Cremation Started 1:ZK' 0- L Time Cremation Completed Type of Container C3 01411d /li�jQ-ti �� _ S�� 2T Remarks Cf AA7/1� 4L la 0-/A i��` 0 TOM Or QRY PIM VIEW COMTBRY Quaker Road, Queensbury, New Fork 12804 Phone (518) Cremtorimm 745-4477 or if no answer cemetery 745-4476 The undersigned requests and authorises Pine View Crsmatosiuet, in accordance with and subject to its Rules and Regulations to cremate the remains of: It Sex) (Name)/ \ /L 7 ✓/k a c�4 0" - U�t ��3 3ta e) J( p C e) (street) (city) who died on of at Jk IJt7 (Place) (A ess) Name and address of nearest living relative or name of person authorizing cremation: -� Sri c AJ YLt; L L (Name) (Address) Relationship to the dec�eJs aed Name of funeral Horne ��)L)C_ IMPORTAI4T t ent that to the best of my knowledge, the deceased has or has no' cemaker in his or her body. (Circle One) I certify that I have the full poster and authorisation to arrange for the cremation of the remains and to direct the1 ino_ ion of the cresiarted remains, that any p P been removed or may be destro"d, and agree to protectir defend and save harmless Pine vies► C " t x-lvm r- any and all claws and demands for loss or damages which say be made a+gaiast then by reason of or connected with the cremation of said remains as directed, whether such claim 'or demands are or are not wholly qro ^ s, false or frawdulent. 1 � c/ l 2 zv�TZ3r i ( ness) ( ss) lei (Signature of Rela or Legal Rep. and Address) Signed on this date: