Weil, Margarette _ 1
I
Pine OF QUEENSBURY
Pine View Ce"Ietery and CreM410riunI
11 Quaker Rood, Queeushury, NY. 12804.5902
(S I8)745.4476
htrP:II�%v%v.queensbu (518)743.4477
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Funeral Director: rE
Name of Deceased: 1
Case Number.
Date of Cremation:
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Retort: T vwc _
f I C Time ��-
Cremation Started: M
Time Cremation Completed: 9 S p
TYPe of Container: l 114
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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 undwsWeedmqwftand authorizes Pine View Crematodum,in accordance with and subject to Its Rules and Regulations to
(Sex)
vI t z p
( (City) ( ) (7Jp Code)
who d on day of 2OjE:
at v •_
( ) ( )
Name and address of nearest ' relative or name of person cremation.
Relationship to the deceased
Fill
Name of Funeral 1-tome
IMPORTANT:
I represent that to the best of tiny ivtowiedge,the deceased(has)cz
ea no) alter.deflbriNator,battery,battery pack,power
tell,radioactive Implant or radioactive device in his or her body.
I certify that I have fop power and authorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,do any personal possessions have either bow removed or may be destroyed,and agree to protect.defend and
save harmless Pine View Crematorium
cremation
�remains as directed,whend demands ther suds demands a s damages which may orwenot wholly
against them
by reason
gground
(witness) Address)
tore and Address of Relative or legal R Iva)
Signed on this date:
Deposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18,2007