Taylor, Marjorie �O O
F QUEErV,593U,�yW PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSB'-My- NEW YORK 12844
(518) 745-4476 (518) 745-4477
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Funeral Director
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dame qtof Case#. S
Date Of Cremation
U'110 6 U ZUU7
Time Cremation Started
7 .Z S-
Time Cremation Completed 11136
Type of Container C �ft
Remarks
TO
`10VF �:�c�
. TOWN OF QUEENSBURY �� 7
PINE VIEW CEMETERY !t
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
(Name ) (Sex )/
(Street ) (City) (State ) (Zip Code)
who died on day of
pA /�, L
at [" , lC�-- N1�, .,� CIS �„ Ave, �,ilj S. J11.
(P1 ce) (Address )
Name and address of nearest living relative or name of person
authorizing cremation :
I/ E -i Save
ame) (Address )
Relationship to the deceased
Name of Funeral Home E ►'✓Sth61Zk Fun), i4otv)E Zn)L•
IMPORTANT:
I re r the best of my knowledge, the deceased has or
r
as no pacemaker ' n- is or her body. (Circle One)
I certify that I 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 demands are or are not wholly
groundle , false or fraudulent .
itness ) (Address)
(Sig at a of 4tiv or egal Rep. and Address)
Signed on this date : 5T1L9/q j -