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Wilcox, Louise OF QUEEN.5Bur. �y PINE DER' CEMETERY AND CREMATORIUM WAXER ROAD, QUEENS13 TRY NEW YORK 12804 (518) 745-4476 (518) 745'-4-477 Funeral Director aIvor dame 0V1� (cod Case# � Q Date Of Cremation ---- 3 ' iI- orb Tame Cremation Started ; 11b Time Cremation Completed p , V Type of Container �, ( dl C.a, s Remarks q ; Io (ova lv ; aD� I I I tT I3c) TOWN OF QUEENSBURY PINE VIEW CEMETERY a CREMATORIUM _I, Quaker Road, Queensbury, New York 2804 Phone (518) Crematorium 745-4477 or if no answer Cemetery 745-4476 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) ( ate) '' CZip Code) who died on (© day of 19 _ a t —. (Place) ( dress) Name and address of nearest living relative o name of person authorizing cremation : 3nCL_4ek Wc-" RIC (Name) (Address) I Relationship to the deceased Name of Funeral Home IMPORTANT: I repr that to the best of my knowledge, tie deceased has or has no pacemak in his or her body. (Circle O e) j, i I certify that I have the full power and authorization to arrange for the cremation of the remains and to direct he disposition of the cremated remains, that any personal posse sins have either been removed or may be destroyed, and agree o protect, defend and save harmless Pine View Crematorium from a y and all claims and demands for loss or damages which may be ma a against them by reason of or connected with the cremation of said remains as directed, whether such claims or demands are Dr are not wholly undless, false or fraudulent. '( itness) (Addres's) J(Signature of Relative or Legal Rep. and A 'dress) Signed on this date :