Ayers, Henry Pr"
TO rRN OF QUEEN,5BU��y
PINE VIEW CEMETERY A
QUAKER ROAD, QUEINSB�IYD CREMATORIUM
NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director �tG
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Date Of Cremation
l4 - 00
Time Cremation Started
Time Cremation Completed tU O(�
Type of Container_ (tip 4o4rj rew �
Remarks Or4�15
Vf ,000
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:
Hr- ?4 C.r-s Y ?d )c
(Name) (Sex)
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`� pe aZc�S R a t_1 a"S Ciro v. su
(fit) (City) (fie) Rip Code)
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who died on 1 t day of J 20 a
at W csrsIb it-
(Place) (Address)
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 0 ca a¢ 4.»y �c.-r 8 i)
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has) (has no aker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(C' )
I certify that I have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possess have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Crematorium all daims and demands for loss or damages which may be made against them
by reason of or connected with the of remains as directed,whether such claims or demands are or are not wholly
groundless,false or t.
(Witness) (Address)
I 6w 0.4/1-11-1
TN ^ '—(SIgn#ture4Hd#0dress of Relative or Legal Representative)
Signed on this date:
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 18,2007