Smith, Russell Jr. d '
rwN OF.-
QUEEP�5BUr
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEFrNSBUPY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ MR kr
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Named' J�nl� 1. C .
Case # 7
Date of Cremation , l I
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Time Cremation Started
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Time Cremation Completed U •(�
Type of 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.-
(Names ) 14 )Ic.;il ► 2Cb��l
(street) (City) ^ (State) ip Code)
who died on as 6 day of ,W V 200q
(Place) (Address)
Name and address of nearest livi(�, or name of person authorizing cremation:
(Name) (�,, k —
�r_ e
Relationship to the deceased
NameofFuneralHome M. B. Kilmer Funeral Home
IMPORTANT:
I represent that to the hest of my knowledge,the deceased(has)or no) er,defibrillator,battery.battery pads.power
cell,radioactive implant or radioactive device in his or her body.(CI 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,false or fraudulent.
Milner) ( )
(Signatufe and Addrids of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium 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 1,2009
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:
re 0, .�.
(Name)
1-7 1A KU.
(Stiest) (CRY) ^ (State) Prop Cade)
who died on day of 'W V ZptV
It
4. 1
Name and address of nearest I , or name of person authortrkV cremation:
4p ) r >A _
(Name) A�d�dreess)�
Relationship to the deceased �"V`
Name of Funeral Home M. B. Kilmer Funeral Home
IMPORTANT:
I represent that to the best of my lvwwledge,the deceased(has)or no) ,dBIWIlator,battery,battery pack,power
cell,radioactive Implant or radioactive device In his or her body.(C
1 certify that 1 have full power and authorization to arrange for the cremation of the remains and to direct the disposition of the
Cremated remains,that any personei 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 loos or damages which may be made agaktst them
by reason of or connected with the cremation of said remains as directed,whether such claimor demands are or are not nst t
groundless,false or fraudulent.
( ) (Address)
(Signet and Add TTof Relative or Legal Representative)
Signed on this date: Z/ V/In
Disposition of Cremated Remains
I hereby direct Pine view Crematorium 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 1,2009
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