Kennedy, Allen Sr. Yr
OF
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PINE YTE` Y CEMETERY AND
QUAKER ROAD, CREMATORIUM
QVEENS8URY, NE NY YORK 12304
(518) 745.4476 (518) 745'•4477
ame
Funeral Director
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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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of
Abt,tM KEnitkoy M .
(Name) (Sex)
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(Street) (City) /� /� ( ate) (zip Code)
who led or>< �1du - ' "► day of >'�F'/e i C 20 Q
at 0(e tS Pi ll< P,—t�,C, I aQPAkk -s- 6-fPl1s
(per) (Address)
Name and address of nearest living relative or name of person authorizing creme'
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(Name) /', (Address)
Relationship to the w/FL �
Name of Funeral Home �E��� eallu ''u,,
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IMPORTANT:
I represent that to the best of my Imowiedge,the deceased(has) noaoemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioaclive device in his or her body.(CC )
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 harmless Pine View Crematorium from arty 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,whetter such claims or demands are or are not wholly
groundless,false or fraudulent.
(Address)
ASS L�c Z-�zns� [�—'- Q b - KN I ?moo
(Signature and Address of Relative or Legal R esentative)-
Signed on this dater
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: E�( O / "`�t'� Uii
If pulverization of cremated remains is requested,check here ✓�_
Revision:April 18,2007