Rieben, Grace OF QUEE O
PLNE VIEW CEMETERY AND CREMATORIUM
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WAXER ROAD, QUEENSBLRY NEW YORK 17804
(518) 745-4476 (518) 745-4-477
Funeral Director __
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Name —�cu It ��
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Date Of Cremation j UL. Z
Time Cremation Started Am
Time Cremation Completed 9-: 5o NM
Type of Container I
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12844
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 Rules and Reguotoons to
cremat the remains of:
(Name) (Se�)
Se �� eL R� SG✓,r�,, z.,�r� IU"
(Street) 1S- (City) (State) (zip Code)
who died on day of ^L 20 0'y
all
(Place) Tess)
Name and address of nearest living relative or name of person authorfzJng cremation:
(Name) (Atdd—ressss)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defbrillator or any other battery operated
device In his or her body. (Circle One)
I certify that I have full power and atutlxxtzatlon to arrange for the cremation of the remains and to direct the disposition of the
cremated remalns,that any personal possessions have either been removed or may be destroyed,and agree to protect,deteno and
save harmless Pine View Crematorium from any and all claims and demands for loss or damages which may be made against tr�em
by reason of-or connected with"awmtion of said remains as directed,whether such claims or demands are or are not*tidy
groundless, udulent.
��- � �aPrrt .,,..�,•c._. � �rM�, F C�t.v"'"l /" ( -f-���Z
(Signatum_aan�d Address oTfRe five or legal Representative)
Signed on this date: �), �-� 7 0 b
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If puNertzation of cremated remains Is requested,check here
Revision:January 1,M