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LaBarge, David 2rO � �v QUEEN P 8WE VTE` V CEMETERY AND C QUAKER ROAD, REMATORTUM Q4476 URY' NEW YORK 12804 (518) 745-4476 (518) 745-4477 Name Funeral Director � Date pFCremation Case# _ Crema t i.on �v 0200$ Time Cremation Started •rt M Time Cremation Completed nj Type of Container ����� OV Remarks � EZ Rcl� 2.- Sr Coo(. 4�.LD/Qn 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 authm¢es Pine Vow Cramatoritm,in accordance with and subject to its Rules and Regulations to cremate the remains of: (Name) I �� � (Sear)\ Nrx `A S G 4� L. f i 5 V I (Z ( ) t (may) (State) (Zip Code) who died on day of-CJ2�- 20 O S at_ ��Qe� i� n. ia P (place) I (Address) Name and address of nearest riving relative or rune of person authming cremation: (Na ) (Address) Relationship to the deceased ET-k 0 Name of Funeral Home IMPORTANT: I represent that to the best of my Wiowiedge,the deceased(has)o�acemaker,defibrillator or any other battery operated device in his or her body. (Circle One) 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 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 groundless,false or fraudulent. ( ) (Address) C- 48ignature and Address of Relative or legal R native) Signed on this date: l I a I©?S Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: 1-1 ,, If pulverization of cremated remains is requested,check here Revision:January 1,2006