Dugan, Patrick PLNE
QUEE;VOUT.
VIEW CEMETERY AND
CREMATORIUM
QUAKER ROAD, QUEENSBIIRY
' NEW YORK 12804
(518) 745-4476
(518) 745-4-477
Funaral Direct
Name or'
Date of Cremation Case #
Time `p~
Cremation Started
0
Time Cremation Completed
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Container
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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-
(Name) n
(Sex)
1 S P�a: 55r.. a
(street) r- (City) (state)
who died on (Zip Code)
—�z 1 day of }
2 �
at _2 �;
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(Place) ` c
(Address
Name and address of nearest living relative or name of person authorizing cremation:
(Name) F (Ad �)
Relationship to the deceased S�
Name of Funeral Home
IMPORTANT:
I represent that to the best radioactive
io ctive knowledge,the d
cell,radioactive Implant or radioactive device in his or s o (has flo) maker,defibrillator,battery,battery pack,power
C O
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,fa or fro ulent
n /
(wn CJ to) (Address)
(S' n ture and A of Relative or Legal Representative)
Signed on this date: J G
Disposition of Cremated Remains
I hereby dhect Pine View Crertn to dispose of the cremated remains as follows:
Mai to
0@W 9ffwWments-Pkw9 specify
H puk arization of cremated remains is requested,check here
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