Parry, Griffith OF QUEE9�(s5OU
PrNE VIEW CEMETERY AMj CR 1�
QUAKER ROAD, QUEENSBURY EMATORIUM
(518) 745-4476 t�W YORK 1280a
(518) 745.-4477
Funeral Director r-
NameRRNj
Case#.
Dace Of Cremation oT
Tame Cremation Started
Tame Cremation Completed l
Type o f Container C 1�-►��. (�p�,,-�I � 57' C(�,S�,.
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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
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)
S 8
(fit) kY (state) (Zip Code)
who died on 1 day of--- T(.1 f�kL{ MO Z
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atAURAvA �atCAL- tZ ��,� �t E[LAiUD AVE., ALB ANU�)
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Name and address of nearest living relative or name of person authorizing cremation:
(Name) (Address)
Relationship to the deceased W 1-166
Name of Funeral Home S--T rf'( P.9
IMPORTANT:
I represent that to the hest of my WaMedge,the deceased(has)orM=no)ocemaker,defibrillator,battery,battery pads,power
cell,radioactive implant or radioactive device in his or her body.(C
I om*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 riot wholly
less,false or fraudulent.
1P fW1LZ9, 11 K - ��OEC( )
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(Signature arldrAs of Relative or Legal ReppdsentativeU,
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
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Revision:April 18,2007
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