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Morton, Helen T0UN OF QUEEVBU9KY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name Hof-}Uj Case# Date Of Cremation 4 /$ %cs Time Cremation Started Time Cremation Completed Type of Container rF . psi- Cy.se Remarks rnrjIn 1a a P. M , w► �+ JrC I I S i Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12804 Cemetery Office: (518)7454476, Crematorium: (518)745-4477 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: {- 1 (Name) 11 (Sex)) \J /l 6{7 r GG r� a-n �S C.1 �h Q)ZY Q. (Street) (City) (State) ip Code) who died on $ day ofF� 20 ` �_(Place) (Address) Name and address of nearest living relative or name of person authorizing cremation: [Name) c (Address) Relationship to the deceased JCS h Name of Funeral Home IMPORTANT: I represent that to the best of my knowledge,the deceased(has) (has no) aker,defibrillator or any other battery operated device in his or her body. (Circle One) I certify that I have 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 CrarMtorium from any and all claims and demands for loss or damages which may be made against them by reason of or connected I I cremation of said remains as directed,whether such claims or demands are or are not wholly groundle&"Ipe or,fra u fitness) (Address) -x. (Signatufe and Address of Relative or Legal Representative) Signed on this date: - LAC Disposition of Cremated Remains I hereby direct Pine �View Crematorium to dispose of the cremated remains as follows: Mail to is i:u" & C Other arrangements-Please specify: If pulverization of cremated remains is requested,check here Revision:January 1,2006