Hammond, Willard uY.igLaL_C. ........
TOWN OF q3JR9t
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Funeral Director )NC
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Name IL ILL1RY jfi9/iliv)olv Case # 5
Date of Cremation )0Z 3� J
Time Cremation Started //Zt
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Time Cremation Completed / i36 rift)
Type of Container 1 /rDLJ 17 C.: Jr r Tioktc.Thy
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY ;) : "9
CREMATORIUM _ -
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with and subject to its Rules and Regulations to
creme he remains of:
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(Name) (Sex)
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( Street ) (City) (State) (Zip Code)
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who died on
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(Place) 'I (Address)
Name and address of nearest living relative or name of person
authorizing cremation: 1n,� ,` ^n (/�
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(Address) i
(Name) (-
Relationship to the deceased �C1�
Name of Funeral Home ( 1�`'��' V� ' (S/1
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IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
no paceeaer 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. J ! / / �7 � / 9� �1 (�
W/ 17�' �/`�%i �' i"v/ikl✓ J — 'Fi ` '� 1 -14-12i /:`K(X��:Y �IlL1
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(Witness) (Addre s)
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lAei � . ia_ P y him .;& / Y 7
( gnature of Relative or Legal Rep. and Address)
Signed on this date: /L////8