St. Jacques, Edmond �x
�O 'OF QUEEN,50U
PLNE v-
E'er CEMETERY AND 1
QUAKER ROAD CREMATORIUM
QVEENSSURY' NEW YORK 17804
(518) 745.4476 (518) 745.4.477
Funeral Director M13
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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:
Edmond Rt _ .Tar qup--, Male
(Name) (Sex)
92 Bain Argyle New York 12809
(Street) (City) (State) (Zip Code)
who deed on theseventeenth day of September 20 08
at Gl pnp Fa l l c Nc)spii-a1_ 100 Park Street Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorWng cremation:
Joyce St. Jacques 92 Bain Argyle, New York
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home M. B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
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 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 wholly
groundless,false or fre t.
(Address)
(sig ure and Aftessl6f KelattveVLegal Representat e) /
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: I 1
If pulverization of cremated remains is requested,check here _
Revision:April 18,2007