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Klemple, Margaret OF QUEE BUJ�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745.-4477 Funeral Director Name�u��ti�f � �em ��� Case# Date Of Cremation 2007 Time Cremation Started /AM Time Cremation Completed 9; 30 Type of Container ark a�G17 Z IS Ciq Remarks MA-rno - Nq 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 augwrizes Pkre View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: (Name ) ( (city) {State) (zip Cam) who died on day ot �©0� 20� at ( ) (Plam) Name and add of nearest living relative or of person atdtrortzing cremation: (Nam ) Relationship to the deceased Name of Funeral Nome IMPORTANT., he deceased(has) . (has�) aker. defibrillator,battery,battery pack,power 1 represent that to the best of my 'the his or her body.(C cell,radioactive implant or radioactive device inI certify that i have full power and auttorb ation to art for the cremedon of the remains and b direct the of the have either been rerrroved or may be destroyed,and agree to Protect.defend and save ham*m Pine View any�personal�and all dairns and demands for hm or damages which may be made against them by reason of or connected with the cmmal*cn of said remains as di ectiad,wimew such calms or demands aloof are not wholly groundless,false or fraudulent. CQ D w •., (wKness) (Address) CIA3- `- 50mture and Address of Relative or legal Represerdative) Signed on this date: Disposition of Cremated Remains I hereby direct Pure View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please sPedfy= if pulverization of cremated remains is requested,check here Revision:April 18,2007