Clark, Ralph TOq+N OF QUEEM5BU,�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NTW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /�OI-� K—E 3 1V S
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Name R I'V ��� �� ' C se # 3 o 0
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container Wcv
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
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:
Ralph Clark Male
(NAME) (SEX)
133 lawrence Street, Apt 94 E. Saratoga Springs, NY, 12866
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 31 day of May 20 00
at 131 Lawrence Street, Saratoga Springs, New York, 12866
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mildred Carter, 133 Lawrence St Ant . 94 East, R-S, NY, 12866
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 o as 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 groundleWhIftlin or 1110"41499ons
628 North Broadway
�j 772wL—� 1571f-� -80010001806096 NOW Y$rk 428
(WITNESS) (ADDRESS) (518) 584-5373
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date:
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