Meyer, Jennie �O OF QUEE9V,-53U2r
PINE VIEW CEMETERY AND CRE
QUAKER ROAD, QUEENSBURY MATORIUM
(518) 745.4476 � NEW YORK 12804
(518) 745.4-477
Funeral Director
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Case#. f5-l�
Oa c e 0( Crema t i.on _U
Time Cremation Started a
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Cremation Completed
Type of Container I� _
Remarks
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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) 7454477
Authorization to Cremate
The undersigned requests and authorizes Pine Vlew Crematorium,in accordance with and subject to Its Rules and mutations to
cromato the remains of:
(Name) �-�^— (Sex)
(Street) (City) t Slate) (Zip Code)
who died on a. dey of lr 209
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at // e✓ .�is� cep - L. �f Yr , V7-
(Place) IAddress)
Name and address of nearest living relative or name of person authorizing cremation: WL
(Name) (Address)
Relatlonshlp to the decoased' /,C.lf�aL1.e X4C,
Name of Funeral Home!%�Odr
IMPORTANT;
1 represent that to the best of my knowledge,the deceased(has) (has no) cemoker,defibriliatoror ady other battery operated
davlce In his or har body, (Clrclo One)
I carifty that I have full power end authortzalion to arrange for the cremation of the remains and to dIrect the disposition of the
cremated remains,that any persona(possessions have either been removed or may be destroyed,and agree to protect,defend and ,
save harmloss Pine Viow Crematorium from any and all claims and demands for loss or damages wNch may be made against thom
by reason of or corviectod with 1h Cremation of sold remalns us directed,whathar such claims or demands are or aro not wholly
groundless,false or fr u ui
( ilness) address
` i
(Signature and Addr ss/ Retotive or Legoii R'epresenla ve
Signed on thls\te:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the Cremated remains as follows:
Mail Io
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here
RCvlslon;January 1,2006