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TINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD. Q;i E 798.472G
9U UY,
NEW YORK 12801
(5I8) 793-9777
Funeral Dirictor ,
5d n� Case No.
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Time Cremation Started 1e t Od
Time Cremation Completed < �✓ � As- D
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY *43
&
CREMATORIUM
Quaker Road, Queensbury, New York 12801
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Sorev\ rol LA.
(Name) (Sex)
`ab Ave_ c
(Street) (City) (State) (Zip Code)
who died on a day of 1/F °r 19 1(
at (,Le....5��1t5 1-1ec 4L GLe,, 'IS
(Place) ) (A, dress)
Name and address of nearest living relative or name of person authorizing cremation: (�
(cr I T e�-,-c 1 � & c 6jrce..1F": (4k
(Name) (Address)
Relationship to the deceased ►1
Name of funeral home �S a/L -V1/4-•1/4 c.f.A t H
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 claims or demands are, or are not, wholly
groundless, false or fraudulent.
(Witness) (Signature of Relative or Legal Rep.)
Zf C ✓w1a- Hit (of:441G yap PPLe✓ Ave,) 6cr;A.-5(1
(Address) ) (Address)
Signed on this date I , /g7