Reichenbach, Ralph OF QUEEN,5BU�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_
NameRF�Cken ECL Case# 31A
Date Of Cremation --7 c)
Time Cremation Started A ti
Time Cremation Completed
Type of Container r,,1i T��,
Remarks
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TOWN Oi=; uEENSB!jRY
PINE VIEW!CEMETERY
CREMATORIUM
Quaker Road, Que&r,Ibury, New York 12804
Phone(51;8)p �74 r 17,(if no answer)
Ceme ery 745-d4''f6
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:
PAI& eY - N Male
(NAME—) (SEX)
: t
PO Box 828 Bolton Landing, NY 12814
(STREET) (CITY) ',' (STATE) (ZIP CODE)
who died on 2nd day-'of July 20U6
at Ft. Hudson Health Care Center, Ft. Edward, NY
(PLACE) (ADDRESS)
Name and(address of nearest living relative orrname.of person authorizing cremation:
has RW-rA- Q_, FR2 Stewart Ave. Bolton Landing, NY 12814
Relationship to deceased_.
Name of Funeral Home Alexander-Baker Funeral Home,
IMPORTANT
I represent that to the best of my knowledge, the deceased has or h n acemaker in his or her
body. (CIRCLE ONE)
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,ct mated remaj ,q;sthat any;pe pttal possessions have either been
removed or may be destroyed;ari ree.tp) teoL X efen�4, ��re.harrMess Pine View
Crematorium from any and 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 ciai are or are�hbt wholly;;groundless, false nor fraudulent.
WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE/OR LEGAL REP.AND ADDRESS)
Signed on this date: �2/d�'