St. John, Kenneth OF
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PINE VIEW CEMETERY AND CREMATORIUM
QUA-KF-R ROAD, Q( EF-NSgURY NEW PORK 1280a
(518) 745-4476 (518) 745-4477
Funeral Director
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Date OF Cremation Z - c6 — 0s
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T ;me Cremation Completed u —
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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
t.
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its mat Rules and Regulatans to
cree the remains of:
(Name) (Sex)
V
(Street) (City) (Stale) (Zip Code)
who died on day of Tr 20 OX
at al_�" Q--
(place) (Address)
Name and address of nearest living relative or name ®
e of person auth
�orizing cremation:
r iA 1 M - /'I.l-t•.�J IKs- V i L
( ) ( Address
Relationship to the deceased '^t
Name of Funeral Home Gh 5 rr "E N c_
IMPORTANT:
I represent that to the best of my Iv�e,the deceased(has)ot_( as r�pacemaker fibrillator or any other battery operated
device in his or her body. (Circle One) _-
I certify fhat 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 arty 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
groin fraudulent. 2 / I
Aw-
Wftness)t (Address)
ignature and Address of Reldtive 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 puNertzation of cremated remains is requested,check here
Revision:January 1,2006