Cornwell, Margaret r7-O
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O� F QUEE
P'NE YI �����1 �.J
EW ,CEMETERy AND CREMATORIUM
QUAX.ER ROAD, QUMENSBURY NEW YORK 128o4
(518) 745.4476 (518) 745'.4477
NameFuneral Director
Gr' ate'( / /,
1 1 Cut'^,�dH C8S2# 03
Date Of Cremation
Tame Cremation Started Lv
Time Cremation Completed
Type of Container /
C Qr u Cc��
Remarks
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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 remains of:
(2. /2 AJ i;J
(Nam) � (Sex)
L/ / tjbSi cJ a /2,ffo
(Street) (City) (SUK6) (ZIP Code)
who died own �_ f/ day of j' 20-�
(Place) (Address) /
Name and address of nearest living relative Or,", of 00"t"n"
7=
t_a cJ` .S-Z
Name (Address)
Relationship to the deceased S -ll)
--p -
Name of Funeral dome
IMPORTANT: no) defibrillator,ba�Y�battery!� power
I represent that to the best of my{vrowledge,the deosase ��
cell,radloective implant or radioactive device In his or her body.(C
1 certify that 1 have ful power and authorization to Marge for the awnation of the remains and fo direct the disposition of the
cremated that any persarel possessions trove eNa been removed or may be destroyed.and agree to protect,defend and
save harmles View Cremelork m from any and al Anima and dernenrls for loss or rim A gag which may be made against them
by reason or fhe cremation of said remains as d MclK Wh9d er such deinrs or demands are or are not wholly
trtess} ( )
�( Vnai�mwidAddress of Relative 1 Representative)
Signed on this dale: 2 f�c( Z b O S
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mad to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,check here
Revision:April 18.2007