Ashworth, Grace �Q O
F QUEE9\�5OUTO�-'QV
PINE VIEW
CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEFNSBURY, NEW FORK 12844
(518) 745.4476 (518) 745*-4477
Funeral Director a4p
Dace Of Cremation 3— ��- O� Case#
Time Cremation Started
1 Zo m
Time Cremation Completed
11 �vv
Type of Container
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Remarks IST
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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:
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(Name) (bex)
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(Street) (City) (state) (Zip Code)
who died on day of mid/Le-,
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(per) (Address)
Name and address of nearest living relative or name of person authormng cremation:
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(Name) (Address)
Relationship to the dew P A v a M-EJ n=
Name of Funeral Home M G R/� /iV
IMPORTANT: defibrillator,battery,battery Pam,power
represent that to the best of my WaMedge,the deceased(has)o P am•
cell,radioactive implant or radioactive device in his or her body.(Circle O�niee)
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 possession 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 remain as directed,whether such claims or demands are or are not wooly
groundless,false or fraudulent.
CL /� /K c>,P tiy=
Mf ) (Address) '
na Relative or Legal Representative)
Signed on this date: -7 <> >
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as hollows:
Mail to Lf /2A JAI*c
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Other arrangements-Please specify:
If pulverintion of cremated remains is requested,check here--,
Revision:April 18,2007