Curran, Virginia OF QUEE BUQ�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEF-NSBURY, NEW YORK 12804
(518) 745-4476 (518) 745•-4.477
Funeral Director
Name y,r ini�
Cvrf,-r)n Case# 5 3-
Date Of Cremation
Time Cremation Started 7: 3 6
AM
Time Cremation Completed 1:, ,-1<- hM
Type of Container C'1rcfbo'�� �
1EC CHst
Remarks
MI.A 1� yp K' Ail
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office:(518)7454476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the 9remains of:
/y 2 C r.J 1)0- A C t K- /-6r"7 92Z -
(Name) (SOX)
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(Street) (City) (State) p—Code)
who died on day of b 67:_1 20 d
at
(Puce) ( )
Name address of fiving relative or name of person authorizing cremation:
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(Name) (Address)
Relationship to the deck lam_ f
Name of Funeral Home �.
U
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or no) alaer,defibrillator or arty other battery operated
device in his or her body. (Circle One)
I certify that I 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 hermleec Pine View Crematorium km arty and all dairrts and deaterds for loss or damages which may be made against them
by or connected n the cremation of said ronhetha as dkocted,whether such claims or demands are or are not wholly
grou7(7T
� �'Z t/rd
(Witness) (ass)
ty
(Signature and Addr of R or Legal Representative)
Signed on this data. L
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mali to
Other arrangements-Please specify:
if pulverization of cremated remains Is requested,check here
Revision:January 1,2006