Gamble, Winifred OFl.l��
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PINE VIEW CEMETERY AND CREMATORIUM
QUAXER ROAD, QUEENSBL1RY, NEW YORK 12804
(518) 745.4476 (518) 745•-4477
Name Funeral Director_
Case# 3 �
Date Of Cremation
1 r V �3 s, 7W V
Tame Cremation Started C/
Time Cremation Completed
Type of Container /
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Remarks s
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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 Rules and Regulations to
cremate the remains of:
(Name) V (Sex)
7 q< d p i s 1a `
(Street) ) (State) (zip Code)
who died on ! 1 day of Q 20!9! •
(fie) (Address)
Name and address of nearest living relative or name of person authort ing cremation:
Q Lle '
( e) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
represent that to the Mast of my knowledge,the deceased(has)or has no) maker,defibrillator,battery,battery pack,power
cell,radioacti
ve implant or radioactive device In his or her body.(Cf
I certify that I have full power and author¢etlon 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 Ions or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,whether such claims or demands are or are not wholty
groundless,false or fraudulent.
V\K
ness) (Address)
(Signature an(d�Address of Relative or Legal Representative)
Signed on this date: wp/,ole
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 puNertmtion of cremated remains is requested,check here
Revision:April 18,2007