Ferrone, Joseph J TO r N, OF Q7JFuTy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4.477
Funeral Director \►� � o����
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TOWN OF QUEENSBURY r"
PINE VIEW CEMETERYl'i, 3
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CREMATORIUM •
•
Quaker Road,Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
•
• •• • 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:
— _ , \\ R LE • •
(NAME) . ,,,-. • (SEX)
cQT QLPM- RS), LA ( o ffES)T TE S CPCOD D.$ 4
(STREW (CITY) ( )
x
who died on cL C • day of ') E.(FTT' FK_ 20 Q 3
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PLACE - (ADDRESS) ,
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Name and address of nearest living relative or name of person authorizing cremation:
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12 k-VC\ ._ ` . S I VL P ROCJ& ?.-S?, } LAe
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Relationship to deceased Pelt w\-EtZ ••
Name of Funeral Home F'a'R-9'SRu 1)EPkl_ v>>>iVC. rF LAI<F -, r_CrE
IMPORTANT
I represent that to the best of my knowledge,the deceased as o has no p cemaker in his or her
body. (CIRCLE ONE)'-r'r;1
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
iC ematorium 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.
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TNESS) (ADDRESS)
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s() (SIGNATURE. F.RELATIVE O LEGAL REP.AND ADDRESS)
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• Signed on this date: \ e aO O.
• P.O
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•
103
PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY PURSUANT TO NEW YORK STATE PUBLIC
HEALTH LAW SECTION 4145(2)(B)
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
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2. DATE THE BODY WAS DELIVERED
3. NAME AND LICENSE NUMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
S s\ R o rof
5. NAME OF PERSO IN CHARGE OF CEMETERY
C)r•NA.< 4.-4,Q
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
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7. SIGNATURE OF PERSON IN CHARGE OF CEMETERY
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8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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9. SIGNATURE OF CEMETERY E PLOYEE WHO RECEIVED BODY
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