Springer, Betty f
,2I QUEE:jl�rBUT�r
PINE DER' CEMETERY AND CREMATORIUM
QU&Y-P-R ROAD, Q(�EENSBI_rRY, N,W YORK 128o4
(518) 745.4476 (518) 745.•4477
Funeral Director
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Quaker Road, QueensburY► New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to cremate
the remains of:
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who died on of
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Name and address of nearest living relative or name of person
authorizing cremation:
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(Name) (Address)
Relationship to the deceased Sd'Ll-
Name of Funeral Home J Luau. \
neoRTAW:
I re resent that to the best of my knowledge, the deceased' as or
s no acemaker his or her body. (Circle one)
a,L- o 10, ,Ud- //O-f authorization to arrange
I certify that I have the full power and
for the cremation of the remains and to dot the disposition of
the cremated remains, dthat any personal possessions have either
or may be to protect a, defend and
been removed rim frcie any and all claims and
save harmless Pine vim or damages which maybe made against them by
demands for loss _ as
reason of or connect claims a o= cremati°mare or are not holly
directed whether such
groan a s, false or fraudulent. Q&3 Q
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(W mess) ` ( s )
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(s ature o R at or L gal Rep. an Address)
signed on this date: - 6