Post, Michael OFL9��rL'Z` B
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PINE YIE'W CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Date Of Cremation Gf{� Z
Time Cremation Started c,
Time Cremation Completed j Zo
Type of Container
Remarks
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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:
naQ.� C Pest 1�
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(Name) l ( )
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(Street) J (may) .L (
who died on
Clay of_� 1 e(Y1 20�
sn- 5Fn l.,ls at
(Ad
ess)
(Place)
Name and address of nearest living relative or name of person authorizing cremation:
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(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT: the deceased( )<� ) fir,defibrillator or any other battery operated
1 represent that to the best of my knowledge.
device in his or her body. (Circle one)
I certify that I have flit power and samroation to arrenge for the cremation of the remains and to direct the disposition of the
created remains,Itud any personal possessions have either been removed or may be destroyed•and agree to tom.defend and
save harmless Pine View Crernaiodum tram any and al claims and dernands for loss or damages whidi may be made against them
by or connected with c rernatiorr of said remains as dreaded.whather such claims or derrands are or are not wttoNy
(Address)
J
(Sign ' e and Address of Relative or Legal Representative)
Signed on this date: O T
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Man to
Other arrangements'Please specify:
if pulverization of cremated remains is requested.check here
Revision:January 1,2006