Albert, John BURY
. (7��T�N OF
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW Y.ORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director I/��15►„0fq
Name To A[L, Case # LM3
Date of Cremation VC4v11pf 19 7005
Time Cremation Started
Time Cremation Completed
Type of Container a-c ����rA P-w1r 4 r ? C
Remarks ;
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
s Cemetery Office:(518)745-4476, Crematorium: (518) 745-4477
t
Authorization to Cremate
The undersigned requests and authorizes Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
creme remains of
(Name) (sex)
.r
(Street) (City) (State) (Zip Code)
who died on 5 day of 20
at -
(Pialce) )
Name and address of nearestt fivingg relative or name of�person authorizing cremation:
AL a 1 r'l
(Name) (Address)
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
I represent that to the best of my Ivowledge,the deceased(has) has no)pacemaker, or any other battery operated
device in his or her body. (Circle One)
I certify that I have full power and audwization to arrange for fhe 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
less Pals _ / / i
v 0 -m%
(536nbture a5cTF4dFegs of Fyalative or Legal Representative)
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Signed on this date' 0 ,+ 1 / ,,
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Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
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Mail to
Other arrangements-Please specify:
If pulverization of cremated remains is requested,&tact two
Revision:January 1,2M