Smith, Grace ,1
TOWN OF QUEENSBURY
Pine Virtu Cemetery and Cietuntorium
11 Qtinker Road, Qneensbury, NY. 12804.5902
(518) 745.4476
hitp://www•queensbury.net (518) 745.4477
Funeral Director: —
Name of Deceased: —r1;
Case Number. LIL�
Date of Cremation: 3
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Retort: C w of C l 5' C!'�5
Time Cremation Started: Zp
Time Cremation Completed: 1 10
Type of Container. /
Remarks:
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" HONIe of Natural Beauty ,,. A Gnocl Plnc• e to Live "
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476,Cremtorium: (518)745-4477
Authorization to Cremate
The undersigned requests and ewes Pine View Crematorium.In accordance with end subject to Its Rules and Regulations to
cremate the remains ot•. _J
(� (Sex)
(
tie
(sweet) (cItr) (Slide) ( p )
who died on r day of 2W—
Sral
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at _&Ajaj4A6jd
(place) O
Name and address of nearest Oft or name of authorizing asmation:
(Name) ( ess)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my ionowledge,the deceased(has) (hes no) maker,deiibr�ator,battery,battery per,per
cell,radioactive implant or radioactive device in his or her body.(C
I cw*that I have fur power and arlhorb a8on to arrange for the crenrafion of the remains and to dived the disposhion of the
crenated remains.ft any per'rrs -na have eown been removed or may be destroyedk and agree to protect.defend and
save hmmkw Pine View QrenreWMin from any and as delete and derrrarn I far lm or vA*:h may be made against them
by reason afar cmvxmd wih the cremedon of said ramairw as tirecisd,wtreflrer such Forks demands are ar are not whoNy
groundless,false or fraudulent.
( )
(Signature Address of Relative or legal Representative)
Signed an this data. ci
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mal to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here
Revision:April 18,2007