Guy, Michael R TOWN, OF QU \[S$' URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director JI 064,r..ILc9N �-} /l 1 `- \-1
a-eft1 I (/ A ldE \R l Case#
Cremation 1 — 5 " 2,ocieL,-3
." e Cremation Started • 9 '3 a t "
-e Cremation Completed ) 2- a--® 1 ''V`‘
of Container 0 'C3 j141 `` — V3
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TOWN 01= QUEENS000Y
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road. Queerrsbury. New Yolk 12604
Phone (5111) Creinatoiiunr 745-4477 (il nu answer)
Ceinetery 745-4470
AUTHORIZATION 10 CREMAI E
•
The undersigned requests and authorizes Dine View Uieinatuiiuni. in aeeuidance with and subject
to its Rules and Regulations to cremate.the remains el:
� �(NAME) a (SEX) )�
' 7//G�.c r 117 V Y' 1 7r- 01.5 t-Z•f') If�-77 /v •?
(STREET) (CITY) (S1A1E) (ZIr3✓CODE)
who died on I.:9L9/69 day of 20
at
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
•
Relationship to deceased
•
Name of Funeral Home ���z , -�1�n� FL) ) 4
IMPORTANT
I represent that to the best of my knowledge, the deceased has 0, ilas r10 acemaker 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 o demands are or are not wholly groundless, false or fraudulent. �7
(WITNESS) (AD RESS) /
X _a
,rx J. /2,d i.at-tu)
(SIG URE OF RELATI OR LE�AL REP. AND ADDRESS)
Signed on this date: •