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Clute, Richard TO Y V N OF QU E B lrl -r�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURy, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name icy e,�c� ��� Case# Date 0f Cremation Time Cremation Started 1b r Time Cremation Completed "(-o Type of Container C1(-i.L /­4(1"!- S Remarks �= 30 S��P1 A C-1 r: i- 1 .`,a Town of Queensbury Pine view Cemetery and Crematorium 21 Quaker Road,Queensbury, New York, 12804 Cemetery Office: (518)745-4476,Crematorium: (518)745-4477 Authoriratior►to Cremate The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to the remains of: rem � ) Male, - (Nam)Q rl Galr1 �q (©t'1 �r lrCl,� (Zip Code) _—J (City) e) (street) 17 -*to died on day of �0 20QG n Of- n at—F [ ) (Ph") Name and address of nearest Wing relative or name of person authorizing cremation: (Name) Relationship to the deceased Name of Funeral Home IMPORTANT: maker.defibrillator or any outer battery operated I represent flied to the best of my Ivrowiedge.the deceased(has)or no) device in his or her body. (Circle One) I certify that I have full power and audxxbzdw to arrange for the cremation of the remains and to d� d o¢agree to protect,defendand cremated remains,that any p p have ether been removed or may be destroyed' save harmless Pine View Cremstorlum front wW and al claims and demands for loss or damages which may be made against them by reason of or connected with the cxertrefion of said remains as directed,whether such claims or demands are or are not wholly g less,false or fraudulent. 'r mr� C '(�(witness) (Address) EL and Address of Relative or Legal Represerttath+e) Signed on this date: �' 'Q - Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to other arrangements'Please wow- If pulverization of cremated remains is requested,check hweX— Revision:January 1,2006