Trempe, William 4,
• TOWN OF. QEE \/ B l..l
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director tl [ Krt. _.
Name ✓J t I I 1 c,` I re,n, c.
Case # 5 U1
Date of Cremation fi Jtihucry 11 7
40
Time Cremation Started $% tic
Time Cremation Completed 111ji )
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Type of Container Rv CV 11 t")FC>Q19 F1ts±-{ kt
Remarks :
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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
cre1AJThr
ate ains of:
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Lame R-1\ U1/4tuA) DI . \ 0-- b5
(Street)" (City) State
ie1 (State) (Zip )
who d' on 20J
ate iS206 l
(P ) (Address)
7ye and of neares< ing relative or name person fr
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(Name) r (Address)
Relationship to the deceased ( iti V1Cel-ti
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Name of Funeral Home t AU
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) (has no) er,defibrillator or any other battery operated
device in his or her body. (Circle One)
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 cremation of said remains as directed,whether such claims or demands are or are not wholly
grou less Ise or fra u
i
ness) (Address)
n .
Signature and of Relative or Legal Representative)
Signed on this date: 1?/3i1°7
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 1,2006