Roskowinski, Bonnie OF l,L L
2 .,SB u lk
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QVEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4.477
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Funeral Director
Name 7,,,
Case# 3eL
Date Of Cremation 111,
_ 11 u1� L 70v
Time Cremation Started
9, 1S X
Time Cremation Completed
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Type of Container---Z—V" CA
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Remarks
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Town o Q ry
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-447
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Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
(
(Name) (sex)
'f DD U 1e Rd ff-, }\)Y_
(Street) (City) (State) (Zip Code)
who died tt on/ b day of 20
at r,� YJ c r--1
(Piece) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
L¢Lara Ros k awj,2
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) maker,defibrillator,battery,battery petit,power
cell,radioactive implant or radioactive device in his or her body.(Ci
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 ham less Pine View Crematorium from any and all claims and demands for loss or damages which may be made against them
by reason of or connected with of said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
�u-
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(S n u of Relative or Legal Representative)-
Signed on this date: O�
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows: j
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Mail to
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Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
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Revision:April 18,2007
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