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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSgURY, NEW YORK 12804
(5 18) 745-4476 (5 18) 745-4477
Funeral Director ++'�
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Date Of Cremation ;v _ 11 _
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Time Cremation Started
Time Cremation Completed 013°
Type of Container
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 undersigned requests and aut atws Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of: _
rdcxka n
(Name) `sexT,L Co
(Street) (City) (State) ( )
who died on 15 day of 20 D&p
at 7� Ftpr a d rS►Ix+6-rN Ak& S
(Place) )
Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased
Name of Funeral Morse
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that 1 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 Crematorium from any and all daims and demands for loss or damages wr"may be made against them
reason of or conneded with the cremation of said remains as directed,whether such claims or demands are or are not wholly
less, fraudulent.
t � 'x -k-JL
(Address).
A 013
(Signature an Address of a or Legal Representative)
Signed on this date: I 1 jjD3
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
It
Other arrangements-Please specify: - -If pulverization of cremated remains Is requested,check here,C
Revision_January 1,2006