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Gannon, John s a TO`WN OF" QUEEN,5BU Ky PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name S©lllq C4.-dA&At Case # a l( c, Date of Cremation — Time Cremation Started �1j qtc grfn Time Cremation Completed /d4 d/ I Type of Containere—"'AA.0,6b/9RD Remarks : TOWN OF QUEENSBURY PINE VIEW CEMETERY CREMATORIUM 0-�01, 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 cremate the remains ofi JOHN GANNON MALE (Name) (Sex) NOTRE DAME STREET FORT EDWARD, NEW YORK 12828 (Street ) (City) (State) ( Zip Code ) who died on 22ND day of APRIL 2001 at 12 NOTRE DAME STREET, FORT EDWARD, NY 12828 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremation : DARLENE GANNON 12 NOTRE DAME ST. FORT EDWARD, NEW YORK (Name) (Address) Relationship to the deceased WIFE Name of Funeral Home M. B. KILMER FUNERAL HOME IMPORTANT: I r e to the best of my knowledge, the deceased has or ha no pacemaker n 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. Qgk�K� A . r3. l� (Witness) (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date :