Mohler, Donald OF
QUEEN,5BUTr
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLJEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
I Funeral Director_ A 0
Name o�tltl muhlc'(
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Date Of Cremation
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Time Cremation Started
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Time Cremation Completed 7-0
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cermetery 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 remains of:
( )
(meet) J (City) (State) (ZP )
who died on / S� day of L► 7 r = 2Q
at �� /-L S
(�) )
Name addre�d nearest reledv:�nerm of persona77
�-
(Name) �ess)
Relationship to the deceased )
Name of Funeral Horne )--v `(/•c J r1
IMPORTANT:
represent that to the best of my iQwwiedge,the deceased(has) no) maker,daNxiWor,battery,battery peck,Power
cell,radioactive implant or radioactive device In his or her body.(
I certify that I have full power and eutlrorbstbn 10 arrange for the cremation of the remains and to direct the disposition of the
qrmeeson
that any, possesions have either been removed or may be destroyed,and agree to protect,defend and
from any and all claims and demands for loss or damages which may be made against them
cremation of said remains as d`ocied.whether su�chh�ck nrss or demands are or are not wholly q
(Widress) )
6( and
or legal Representative)
Signed on this date:
2 °
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2W7