Bonner, Patrick f,
'7-n' rktN OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURy. i EW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director R68� T
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Date Of Cremation O g
1:
Time Cremation Started
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Time Cremation Completed
10: 30 / I
Type of Container Clog C",;.5 •
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Remarks
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
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 f day of c)A f- �z 200
oe
at
(PLACE) (ADDRESS)
Name and address of nearest riving relative or name of person authorizing cremation:
Relationship to deceased
Name of Funeral Home p ��
t
IMPORTANT
I represent that to the best of my knowledge, the deceased as r s o pacemaker in his 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
.. ematodum from any and all claims and demands for loss or damages which may be made
ether
against them by reason of or connected
; with the cremation of said remains as directed,
such claims or demands are or are not wholly t.
holly groundless,false or fraudulent
(WITNESS) (ADDRES
f
(SIGNATURE OF RELATIVE OR.LEGAL REP.AND ADDRESS)
Signed on this date: z o