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Vanguilder, Leslie .r TOWN OF QUEEVBU, y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director k M Name ` 11A Case # �5© Date of Cremation A2 s c3 Time Cremation Started "L'6--�4M Time Cremation Completed!Z'_HQ i9 -M r Type of Container 4 i14922z4lf,0 y Remarks : / �1'39 4'7 i M ► Z%/a- �' V-:r-4 ,An TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM /0 Quaker Road, Queensbury, New York 12804 •l" 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: LESLIE A. VANGUILDER MALE (NAME) (SEX) 653 COUNTY RT. 31 SALEM NY 1286q (STREET) (CITY) (STATE) (ZIP CODE) who died on 2ND day of DECEMBER 20 00 at PLEASNT VALLEY INFIRMARY, ST * RT. 40, ARGYLE, NY 12809 (PLACE) (ADDRESS) Name and address of nearest living relative or name of person authorizing cremation: DOROTHY MATTISON 653 CO. RT. 31, SALEM, NY 12865 Relationship to deceased DAUGHTER Name of Funeral Home M. B. KI LMER FUNERAL HOME IMPORTANT I represent that to the best of my knowledge, the deceased has o has no cemaker 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. A'Z"'X4'4— (W NESS) IF (ADDRESS) (SIGN URE OF RELATIVE OR LEGAL REP. AND ADDRESS) Signed on this date: J�`�a/O D