Duchesneau, Marie OF
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QUEp CREMAT ORIUM
(518) 745.4476 URY, NEW YORK 128N
(518) 745*•4-477
NameFuneral Director
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518) 745-4476, Ciernatodu►n: (518) 745-4477 '
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,In accordan"with acid sub)ed to its Rules awl Regulations to
cremate the remains of:
N 4 i6 D LW-k eS�EAL� P.--- - ------ --- - -
(Name) (Sex)
2352 �idae 12d. -- --��--
(Street) ll (C'y) (State) (zip code
who died on I�T day of u ber --- --- 20 Q�
(Pia,ce) (Address)
Name and address of nearest living relative or name of person authaiziirg crematkxr:
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(Name) (Address)
Relationship to the deceased ltauk-kli,-
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Name of Funeral Home V bulaValG7
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has no -ernakef.,defitxillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Cir a ne)
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 fraudulent.
(Address) —---- --
(Signature and 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 remalns as follows:
Mail to _
Other arrangements-Please specify: t u i vu-t Ik_L 4(JI'V`+L...If pulverization of cremated remains is requested,check here
Revision:April 18,2007