Clark, Anna 3
70`�ti OF QUEENSB21
,(�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ ��AKEC�
Name �n,,�, C�ti�(� Case# 377
Date Of Cremation
Time Cremation Started , I . 3G AM
Time Cremation Completed_ 1 , p 1� I
Type of Container Csrc���- w;-01Z19
Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undyed requests and authorizes Pkce View Crematorium,in accordance with and sul*d to its Rules and Regulations to
cremate the ins of.
sex
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(Street) (city) (state) 4Zlp )
who on 2,J S�- U -T- 20L 0 Co
at
(Place) ( )
Name and address of Ihrkig rele*Fs or of peN n cremation:
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(Name) (
Relationship to the deceased -
Name of Funeral Home
IMPORTANT:
I represerit 00 to the best of aW browledge.the deoeaaad(has)or tno) ,deRbriNelor or arty odw battery operated
device In his or her body. (Ckele One)
I certify that I heve full power and sawrizatiorn to anwW for the cremadw of the remains and to direct the won of the
cremated remains,that any parsonel possesslorrs have either been removed or may be destroyed.and agree to prated defend and
save harmless Pk A View Cremewriun from ant►and all A I I and demarde for lose or dernsges which maybe made egai ist Dunn
by ressoo odrsnecied wish We cm.o n of add rernekns as directed,whettrer such clef ordsrrrards are ar are not wholly
or
2-��
(Address
( and Address of or taegal Rom)
Signed on d*date: )2-7/ �'
deposition of cremated Remaft
I hereby direct Pine View Cremewriun to dispose of the cremated remains as Mom:
mm to
otherarrangements-Please seedy:
if Nwrization of cremated remains is requested,check here
Revision:Jararary 1.WN