Labarge, Paul Albert rf-O q+N OF QUEENs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Date of Cremation j ���'� �oao
Time Cremation Started
Time Cremation Completed
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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
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:
Paul Albert LaBarge Male
(NAME) (SEX)
100 Middle Grove Road, Greenfield Center, New York, 12831
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 22 day of January 20 00
at Saratoga Hospital , 211 Church Street, SS, NY , 12866
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Diane LaBarge , 100 Middle Grove Rd, Greenfield Center, NY, 12831
Relationship to deceased Wife
Name of Funeral Home William J . Burke & Sons Funeral Home
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.
Wiliiam J. Burke & Sons
628 North Broadway
(WITNESS) (ADDRESS) Sara-toga Springs, New York 12866
(5p 58 4-5 73
(SIGNATURE OF R A IVE OR LEGALJRIEP. AND A SS)
Signed on this date: C;)_oo
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