Jones, Mary OF QUEE9�S13Urj
PLNE
EW CEMZTERY AND CREMATORIUM
f,IU' ROAD, QVEENSBURY NTW YORK 12804
(518) 745.4476 (518) 745'.4477
_ Funeral Director ST
Name of At off(
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Cased C'
Date Of Cremation
Time 7�
Cremation Started 7; 30
T 1 m e Cremation Completed
9�.26 AM
Type of Container ((II
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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 the remains of
ems'
(Name) _ (,cat✓ST Yin ouf�T It a✓ —�} u
gO
(fit) ( KY) fie) (ZJp Code)
who died on lam/ day of 1 A
L—20 03
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Eep.sBu ram,
(Name) Add )
Relationship to the deceased Al A Co,a7a�R— _-
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Wvwledge,the deceased(has) (has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(
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.
(Witness) ( )
Lk
(Signature and Adoggs of Relative or Legal Flepresentative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pate View Crematorium to dispose of the cremated remains as follows:
Mail to
other arrangements-Please specify:
If pulvertzatan of cremated remains is requested,check here
Revision:April 18,2007