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Lightfoote, Robert rr � • t , rir O O ' r•l�//r`//� U PINE YI ��w ' ER' CEMETERY AND ��J QU�R ROAD, QUep.Ny N CREMATORIUM (518) 745.4476 ' NEW YORK 128C,4 (518) 745.4.477 Funeral Director Av .Fame ` u /r L . Case. �SZ art a Of Crema t i.on Time Cremation 00 Started �f1,0s Tine Cremation Completed Type Of Container Remarks �tiw ZN 6ASF UV q &© 30 M I I I I I • I I I i 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 under"ped requests and authorizes Pine View Cree eWium,in accordance with and subject to its Rules and Regulations to cnamate the remains of: ) (5� G o,IIcors-r vc , � ��. J. , / 7 (Street) rJ (City) ) (Zip Code) who died on 7 of C r 20 at , (Place) ( ) Name and address of nearest living relative or name pwSM SLOWFizing cremation: ootE i�/,o��/ (Name) (Address) Reladonshp to the deceased Name of Funeral Home o AREA IMPORTANT: I represent that to the best of my knowledge,the deceased(has) no) eker,de�etor,battery,battery peck'Power caq,ran odW implant or radioactive device In this or her body. 1 oart8y#01 have ful power and ftewlf oun to WSW for the aemedw of the remains and to direct the disposition of the crenhatad remains,that any P 0 A I hd po---___s have aittrer been temoved or may be deslroyed,and agree to Protect.defend and seem haaltess Ptrhe View 6remebrMnnr from wq and ar dolma Skill W41 br bm Or damages which maybe made against diem by reason of or connected with the aema8on of said laaaihs as drected.wMnrler"IN dstew or danwrds are ar are not wix ft false or O Ci 7 7,�)2�d Address of Relative or Legal Representative) Signed on this date: Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the cremated remains as MOW Mail to other arangements-Please sPOW ff pulverization of cremated remains is requested,check there Revision:April 18,2007