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Leonbruno, Joseph nrM)N OF- QUEE BU -r�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director _ Name f ps e f�� hen�� r Al D Case O • Date of Cremation �o _ f6 - Oq Time Cremation Started .-A C � Time Cremation Completed oo Type of Container �gr�[2 Po ,— P 157` CASE Remarks : LA © � r # uuo Town of Queensbury Pine Yew Cemetery and Crematorium 21 Quaker Road, Queensbury, New York, 12804 Cemetery Office:(518)745-4476,Crematorium: (518)745-4477 Audimization to Cremate The undersigned requests and authorizes Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to cremale remains of: (Sep) (mot) (City) ,,rr "(Siaiee) (Zip Code) who died on t-3 day of 0CL 20_ o 3 �sSB� ^ 1 n'� 1 zg39 (Plow) Address) Name and address of nearest oft retail"or name of person autortting cremation: u C-i9e.a.', 4�' a J�(j3g (Address) Relationship to the decreased�-'"r` Name of Funeral Home IMPORTANT: I represent that to the best of my lavwWge,the deceased(has)or(hda no)pacemaker,deiNhriNator,battery,battery Pads,power call,radioactive implant or radioactive device in his or her body.(Chris one) I cw*that I have full power and authorization to amangs for the cremation of the remains and to direct the disposition of the cremated remains,that any personal Possessions have either beery removed or may be destroyed,and agree to Protect,defend and- save harness Pore View from any and an claims and demands for loss or damages which may be made 898NW them of connected with 'cremation of sold remains as directed.whether such claims or demands are or are not wholly grou s:fates or fra 3 Jr 7 It t7 411 ( ) BWre and Relative or Legal Repres�htathre) •'���. Signed on this date: oc- 13—p Disposition of Cremated Remains I hereby direct Pine View Corium to dispose of the cremated remains as follows: Mail to Other arrangements-Please specify: If pulverization of cremated remains is requested,check here Revision:January 1,2DO9