Setterstram, Henry rh!
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�' CEMrp
ETERY AN
QUA-KJLR ROAD, Ql1E>?NSB CREMATORIUM
URY, NEW YORK 12804
(518) 745.4476 (518) 745.4477
Funeral Director
.Fame
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t C a s e#. C 2
Date Of Cremation
Time Cremation
Started
Cremation u
7 ; me Ccema
Completed 10
' I4h
T
Type Of Container
Fr
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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 undefslgned requests and authorizes Pine View Crematorium,In accordance with and subject to Its Rules any l Regulations to
cr t the remains of:
S -m- - --- - -- -
(Na (Sex)
3� r: bUe rwjsb,^&,, XJ -- 1000yl-
(street) (CRY) 0Zr
(zit)who d ed on �� of � '20 6p
0
at h1h
(Place) (Address)
Na and addr of nearest living relative a me of person autt izirhg crer aticx1:
/ Name (Address)
Relationship to the decreased F-� ,[[
Name of Funeral Noms aio, 'y -0 --- _
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or s,no maker,defrtxillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cir a ,,We)
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 harmless Pine View Crematorium from any and all claims and demands for loss a damages which may be made against them
by reasoffof connected with the creme of said remains as directed,whether such daims or demands are or are not wholly
groundlese or fraudulent.
(W�) (Address)
(Signs a and Address of Relativ Legal Representative)
Signed on this daOd --- ---- - ------- ---
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to -
Other arrangements-Please spedfy: TD _ _
If pulver¢ation of cremated remains Is requested,check here _
Revision:April 18,2007