Kenny, John rrO74N OF QUEEN,5BUP,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director hb rlLNK2
Name �o�,h 'tAn� Case # 3�(5
Date of Cremation
Time Cremation Started
Time Cremation Completed 11 .00
Type of Container g�� ga„a .12AyroRD }- SST c WE
Remarks :
MAPQ B M ME- 1 1° A01
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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
Ja h
(Name) \\ (Sex)
(City) ((�� fate) (Zip Code)
who died On day of�y V C v k 20 S�9
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Name and address of nearest living reiattve or name of person authorizing ration: i
(Name) (Address)
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Retationshtp to the deceased �krvk e C- ?cr-
Name of Funeral Home M . C� - Y\ ' M 2 5-
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IMPORTANT:
j represent
thattive o the beet of my i ni adge,the deceased(has)or�aker,defibrillator,battery,battery pact,power
Implant or radioactive device In his or her body.(Circle
I certify that I have full power and authortzatlon 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 by reason of or connected with the cremation of said remains as directed,whether such claims which may be made demands are or are not�them
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(Address)
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4 Gee �.� C; �t �e
( Ignature and Addr of or Legal Representative) -I s
Signed on this date: a0 n 9
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Disposition of Cremated Remains
I hereby direct Pine View Crematortum to dispose of the cremated remains as follows:
Mail to
Other arrangements-please specify:
If pulverttation of cremated remains is requested,check here
Revision:April 18,2007