Nichols, Nancy • � ._ ^ r - ,.,fit`,{:,:,j,. , . . -- • - _. ,
TOWN OF Q UEENSB UR Pine Virtu Ctnrrtery and Crrulatoriunj Y
21 Quaker Road. Q,rtensbilry, NY. 12804.5902
(518) 745.4476
h"P://www,quecnsbu (518)745.4477
ry.net
Funeral Director.
TLW
Name of Deceased: -
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Case Number. Z
Date of Cremation: r,
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Retort:
Time Cremation Started: lo
Time Cremation Completed: io t o
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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 Rubs and Regulations to
cremate the remains of:
Nang U N►ALAS
(Name) t (Sex)
(Street) (City) _ (State) (Zip Code)
who died on , ` day of J u n P 20
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(Place) (
Name and address of neatest living relative or name persona creme .
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(Name) (Address)
Relationship to the deceased �)t,'LLQ�hvf- Mas&uc�
Name of Funeral Home
IMPORTANT:
I represent that to the best of my ivtowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 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
of or ed with the a remains as directed,whether such claims or demands are or are not whoNy
less,false o< u t 0'
�. (wrtrsss (Address) l C
S 7-
(Signature and Address of Relative or Legal Representative)
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 arts
- :
If pulverization of cremated remains is requested,check here
Revision:April 18,2007