McNamara, John E • TOWN OF QBQJRJ
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director k6LL1
Name T vkh M Qc,,,nc,res Case #
Date of Cremation Eck l3 , Zoib
Time Cremation Started
Time Cremation Completed 10• 5i) Afri
Type of Container (e,r400,1) Po xi P141( j.t ase-
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804 •
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
• 0 AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium. in accordance with and subject
to its Rules/ and Regulationsguj to cremate the remains of:
H cVIN E. 1 1 II�ANmAr-A A '
(NAME) t . • (SEX)
/ 369 (is 1Ti , ctitool t) ANke- N . . /,)8170
(STREET) • (CITY) (STATE) (ZIP CODE)
who died on MI day of I"e6 v n d, 20 j"
at M ^-. 0A/,FA) EQur>/N99 "kid— /G i�i r,','c- 4— S/ Fern d oyef i' A'y
(PLACE) (ADDR'ESS)
•
Name and address of nearest living relative or name of person authorizing cremation:
,4e%J p7 • (VC. AiA0I Ai— 6-1.
Relationship to deceased Lv I F-t
/,d
•
Name of Funeral Home A ,I f.1- � �- . Q=�/ tt�Ale Y�1i\lQ .�R_-
IMPORTANT
I represent that to the best of my knowledge,the deceased has or has no pacemaker in his or her
body. (CIRCLE ONE)
I certify that I have the 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 claimss or demands are or are not wholly groundless,false or fraudulent '`''
(WITNESS) (ADDRESS)
J-7(SIGNATUR OF R TIV OR LEGAL REP.AND ADDRESS) .
Signed on this date: 3` //—d7--• .