Colburn, Bernard OF U� L
Q, N,sB UT�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUBENSBURY, NEW YORK 17804
(518) 745-4476 (518) 745'-4477
Funeral Director
Fame ern� f�� Ce1�j
uys� Case# �a (�
Of Cremation
N C 20 �2007
Cremation Started
to �pl
, . me Cremation Completed 56 P
' rPe of Container �',rc ho�,rU w�
Remarks
2 .30 Pf1
3Go �
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I
it N
TOW OF GUEENS9UiRY
PINE VIEW CEMETERY
a * W
CREMATORIUM
Quaker Road, oueensbury, New York i2864 `
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 743-4476
AUTHORIZATION TO CREMATE
The undersigned reouests and authorizes pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
cremate the remains of: y
6 L0'NA(fir
(Name) (Sex)
(Street ) (City) (State) (Zip Code)
who died on
1`7 Y day of
a tit!
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremations
�;y�cs C�,,1,�z�.��h� ��)�7� �S�: t2t� 9 ,�rQnr� 1��r��►�' �tf� f �--
(Name) (Address)
Relationship to the deceased11:i2eE
Name of Funeral Nome
IMpORTANTs
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that 1 have the 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 claims
and demands for loss or damages which may be made against them by
reason of or connected with the cremation of said remains as
directed, whether such claims or emends are or are not wholly
gro ss, fals n }.
(Witness) (Address)
(Signat ri of Relative or Legal Rep. and Address)
Signed on this dates_ r_'�q,� �j