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Bethel, Daniel r'O 4N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director 191q Name J A�4 Case # ' Date of Cremation Time Cremation Started Time Cremation Completed Type of Container �x �151"©/� �yEOrQ �/ Remarks : 33A ,M ' 5-01 6/M f /�_ q P,,M I �-9 �rM f TOWN OF QUEENS©URY PINE VIEW CEMETERY A CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 745-447.7 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 cremate the remains of: E_ r.. (Name) (Sex) --� I�[n� �{} (Street ) (City) (State) ( Zip Code) who died on -- /L'�! ��( day of at N ` (Place) (Address) b Name and address of nearest livingrelative or na-m-iPldf �'`pe'rson authorizing cremation : RIr3'A {-: ;•1 -':�'..i 1, 1i.J....�S OY• (Name) (Address) '_ Relationship to the deceased Ney Name of Funeral Home 12t5 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 •aut:horization Lu -4r-k3ange � for the cremation of the remains and to direct the disposition of the cremated remains, that any personal possessions have a ther been removed or may be destroyed, and agree. to protect, r' . fend 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 cremat.io.n of said remains as directed, whether such claims or demands are or, are not wholly groundless, false or fraudulent . (Witness) (Address ) (Signature of Relative or Legal Rep. and Address) Signed on this date ; C� "Customer's Designation of Intentions" Name of Deceased: Cremation:— A/�J'A--2 IVV (scheduled Date) (Location) Manner of Disposition of Cremated Remains: El Burial at k] Return to Family El Entombment at 0 Other (specify): I hereby designate the Disposition of Cremated Ren-jauu and acknowledge receipt of a copy of this form. A (Signature) �,,, &,k,% (Printed Name) (Relationship to Deceased) (Address) (Telephone Numlier) "Cremated Remains which shall not have teeny claimed within 120 days from the date of cremation may be disposed of by this firm by Placement in a'columbarium.,, Printed Name of Funeral Director 'Signature of Funeral DAqAor Date or Undertaker or Undert.6t TO BE COMPLETED FOLLOWING CREMATION AND DISPOSMON OF CREMATED REMAINS Cremation: (Actual Date) (Location of Crematory) Disposition of Cremated Remains: (Manner of Disposition) (Location) (Date) Name of Person Making Disposition Signature Date #9 WHITE:Funeral Home Cow YELLOW Family COPY PINK Crematory Copy CUSUMN R.,.4/96