Monroe, Constance Rs
1.
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Pi U'EENSB UR Y
Pier View Ce►Ietery and Creutatoriuu►
17 Quaker Road, Queenshury, NY, 72804.5902
(518) 745.4476
h(rP://w^�v.queensbury.ne1 (S 18)74S•4477
Funeral Director:
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Name of Deceased:
Case Number: Z
Date of Cremation:
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Retort:
Time Cremation Started:
Time Cremation Completed: :3v
TYPe of Container: C:r, _ C1t
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)745-4477
Authorization to Cremate
The undersigned requests and autarizes Pine View Cremetorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
11)�14+vCklr- 1.I
(Nam) (SOX)
915 � �,('id-�
(street) (City) ( ) (Zip Code)
who died on day of 20—
at (t�ace> (Address)
Name and address of nearest Oft relative or name of person augxx¢inD cremation:
(Name) (Address) l
Relationship to the deceased �Q
Name of Funeral Home
IMPORTANT: [ham no di Nator,berry,beery pack.per
I represent thol to the best of my bwwledge,the deceased(has)or )P �
cell.radioactive Implant or radioactive device in his or her body.(Cimle One)
t certify that 1 have lull power and a dlortntioon to anarga for#0 00nation of on reambris and to direct the lion of the
cremated rarmins,*0 arty personal possessions have eMw been rernaved or may be destroyed.and #nay m protect,defend and
made against own
save harmless Pine �' ��uo se disc wtreat such da or 4- .i n P r'are or not wlwilyy
by .
YAV3 C 1�Gt.2
(Signature and Address of Relative or Legal Representative)
Signed on tltis date:
Disposition of Cremated Remains
I hereby ulna ph*View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please WOCNY:
If pulveu#tation of cremated remains is requested,check here
Revision:April 18,2007