Strack, Leon E TO OF QUEE. 513Z1lOr
PINE VIEW CEMETERY AND CREMATORIUM
QUAXER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4-477
_ Funeral Director )`4j G � 1
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=ae Of Cremation
' = ne Cremation Started
: re Cremation Completed '_
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TOWN OF OUE:!I_NSBUP.Y 5, 7
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queensbury, New York t2804
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Phone (5'18) Crematorium 7454477 (if no answer)
C:erne tery 745 447
•
{ AU"THORIZA)ION TO [ REMATE
The undersigned requests and authorizes Pine View Crematorium in accordance with and subject
•irk itd Rules and Regulations to cremate the remains of
Leon E. Strack Male�._ .�.�,.
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!(NAME)
420 Old Military Road, Lake Placid, NY 12946
; (STREET) (CITY)
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December fit}03
di don
11 th day of —�"
at tJihlein Mercy Center,
420 Old Military Rd. , Lake Placid,N•
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f 1 (E'LfAC )...._. ((ADDRESS),
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acne land address of nearest living relative or name of person authorizing cremation:
Rose: M. Strack, 10 Balsam St. , Lake Placid, NY 12946
Relationship to deceased W i e .,,_.._........_.-
Name`of Funeral Home..M._B.,_.C1ark..:..m. Inc_., - 27 ,_fir.antic......AY.e_,...2.I.,.,a. .e. P.ldciSt, NY
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IMPORTANT
1 represent that to the best of my knowledge, the deceased has,or has Do pacemaker in his or her
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body.'I (CIRCLE ONE)
f
e remains
I certifythat I have the full power a nd remains,itthio arrag for the at.ar7y'I�ersorcai possessions nc harvP eitherbeen
to direct the disposition of the cremated
removed or may be destroyed' and agree to protect, defend and save harmless Pine View
agairist e from any andor all
wth and rthe' s tor loss or damages which may be made
crem cremation of said remains as directed, whether
ac�rairist them by reason of
1 soch claims or rnands are or are not wholly groundless, false or fraudulent.
Lake Placid, NY —__
ft5- LL' 27 Saranac Ave. 6
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I'i'?Jr',,.,< Lake Placid, NY
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: )114- 10 Balsam St. ,
Fiign pd on this date: 12/11/03 ......__.ti.w._
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FUN,V52.5
DIRECTORS
Body Delivery Receipt
(Required by Section 4145 - NYS Public Health Law)
A.NAME OF DECEASED PERSON:
(as it appears on burial,cremation or transit permit)
B. DATE THAT BODY WAS DELIVERED:
C.NAME ND REGISTRATION NUMBER OF FUNERAL DIRECTOR MAKING DELIVERY:
/7
(Print Name) (Reg. #)
D. NAME OF FUNERAL FIRM REPRESENTED BY THE FUNERAL DIRECTOR:
(Print Licensed Funeral Firm Name)
E. NAME OF OWNER, OPERATOR,MANAGER OR PERSON IN CHARGE OF
PLACE OF FINAL DISPOSITION WHO RECEIVED THE BODY:
(Print Name)
CHECK (r) IF NO ONE IN CHARGE
F. NAME/LOCATION OF PLACE OF FINAL DISPOSMON:
024 (2/7 --2-1/F-(-x r../, 1 ( /7
(Name) (City,State)
(SIGNATURE of Funeral Director) (SIGI4ATURE of Person Receiving Body)
White Copy-Funeral Director Yellow Copy-Place of Final Disposition Blue Copy-Decedent's Family