Martin, Janice OF QUEENL l.L
,9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director K J
Name Jan,( t 14a 4, Case# L13C>
Date Of Cremation — 0
Time Cremation Started 1,1: 25 r'M
Time Cremation Completed 3 Ib
Type of Container In/ a CKe C���,�{�•;� �� C 5
Remarks
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PIltB V1C i CBM�TBBY
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CMU TOM M
Quaker Road, Queensbury, New York 12844
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AORISATIOIt TO ' E
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
(Name) (SOX)
(Street) (G ty) (3 e) (Z p Co e)
who died on day
day of
ats (
ace) ess)
A, t9
(P a
Name and address of nearest living relative or name of person
authorizing cr tion:
(Name) ( ss)
Relationship to the deceased SL- -
AA
Name of Funeral Home_
atPORT w:
I re resent chat to the best of my knowledge, the deceased has or
as no *ma his or her body. (Circle One)
I certify that I have the full power and authorization to arrange
ion of the ma
the disposition Of
for the crematins and na possessions have either
the cremated remains, that any p to P�tr defend and
been removed or may be destroyed, a�� and all clai®s and
save harmless Pine view Crematorium be a against cthem by
demands for loss or damages which may ,
reason of or connect claims o= des°tee Or of are not wholly
ins as
directed, whether
groan s fal=rfraudulent.
s
,,
—(Address)
(Signature o Re at ve or Legal Rep. anAddress)
i
Signed on this date: