Ashkenazi, Jonathan L O O •
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01/13/2009 11:50 518-792-1287
REGAN&DENNY PAGE 03
2�
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queenabury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium. (518)745-4477
Authorization to Cremate
Tara undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains at
Jonathan Anders Ashkenazi male
(Name) ..(sex) -
31 May Street Glens Falls NY 12i30t
(Street) (city) (State) (zip code)
who died on _ 5 t h - - day of January 20 Q 9
at 31 May Street Glens Falls NY
(Place) (Address)
Name and awress of nearest living ralative or name of person sohor121ng cremation:
Honey Meyer 305 Worcester St. Southbridge, MA
(Name) (Address)
RelatiowNp to the d&mOSed _ Mother
Name ofFLvwaiHome_. Regan and. penny Funeral Home
IMPORTANT:
I represent that to the hest of my knowledge,V*decimsed(here)or 457m Dno psoemeker.defibrillator,battery,battery peck,pourer
cell,radioactive imOtant or radioactive device in his or her body.(Ci )
I certify that I have full Power and 9uthorbBtion to arrange fox the creMetlon of the remains end to d*W the disposition of the
remated remains,!fret any penronai possessions have either been removed or may be do*uyed,and agree to protect,defend end
save harmless pine View crematorium from any and all dalms and demands for logs or damages which may be made'against ale
by reason of or connected vrilth the cremation of said remains as drn�cted, such claims or demands are or are not wltoty
ar iess,false or traudulerd. 3 8 A v b u rn.R C� ,
Les M c e r w �a„f .�, c-r hl ITX)e�s
(WftM s) (Address) o(o 119
�`� ✓ 5
( rs / of Relative or Legal Representative)-
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pie View Crematorium to dispose of the cremated remains as follows,.
Mail to
Other arrangemertis-Plesee apedty: Venf
If pulverization of cremated rename is requested.check here
Revision;Apdtl 18,2007