Sprague, John Sr. OF
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PINE VIEW CEMETERY AND CREMATORIUM
QUAD F-R ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745'-4.477
Funeral Director M ,
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Case# �
Date Of Cremation
GCT Z
Time Cremation Started
Time Cremation Completed I.
Type of Container c
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
crematethe remains of
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1,46KAbasr ROAD A-rl 40 A
Street State)
(Street) (City) (Zip Co )
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who died on day of l J�-> 20_L�
at
(Place) (Address)
Na and add nearest living rel name uthorizing
(Na ) (Address)
Relationship to the t Y/
Name of Funeral Home C '1 F—
IMPORTANT:
I represent tl A to the best of my knowledge,the deceased(has)or has no) er,defibrillator or any other battery operated
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 View any and all daims and demands for loss or damages which may be made against them
by reason of or with the of said remains as ad,whether such claims or demands are or are not wholly
g less,fa udu
"ness) ( ) /
(SIgn6tuW&ndFWress of Relative or Legal Representative)
Signed on this date: DC' D L;Z 0�& a0c
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: rU A)ath
If pulverization of cremated remains is requested,check here
Revision:January 1,2006