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Thomason, Kevin 1 rr"orPI/N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director &LCk Name P \�� Case # Date of Cremation <3 1 QIo9 Time Cremation Started Time Cremation Completed —Tl .� Type of Container 1Q-ca- IQ Remarks : M A T1y < NiOy� V�Z2 C7 q Town of Queensbury Pine Very 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 au torwas Pine View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of: (Nerve) � (sect) �91 ST 1U TI ^ Vb (street) city) (state) VJP code) who died on © day of 20 at 14u Y-n M, (ice) - (Address- ) - - Name and address of nearest I ft relative or name of person authortzing cremation: Do-tlaT� -$ .�..� �l8 s'7:cam•1 g "Se p f.(>Y�s-1 pie") '� . ( ) Relational*to the deceased Name of Funeral Home IMPORTANT: I represent that to the best of larowledge,fhe deceased(hes) no) .detgxidat�,battery,battery Pads+bower call,radioactive implant or radioactive device In his or her body.(Clyde I certify that 1 taus fug power and auftrh adon to stamps for the cremation of Me remain and to direct the disposition of the cremated remaim that any personal possessions hays aver bean removed or may be destroyed,and agree to protect,defend and save harmless Pine View Crematorium k orn amy and ail claims and dernerr. for loss or damages which may be made against Own by reason of or connected wMh the asmation of said remetrra as A acla I vdnew such clal 4 or demands are or are rat wholly a)�-- ""� J 4Q- i4LOA.4—) gR�� false a ( $) and of Relative or Legal Representative) Signed on this date:lJ"".L b 0 9 Disposition of cremated Remains i hereby direct Pine View Crematorium to depose of the cremated remains as foaowa: Mall to Other arrangements-Please spew. If pulverization of cremated remains is requested,cheek here Revision.January 1,2009