Rawleigh, Diane F w
•
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TOrk1)- OF
CEMETERY AND
PINE �' �.J
QUAKER ROAD, CREMATORIUM
QUEENSSURY, NEW YORK 12804
(518) 745.4476 (518) 745•-4477
Funeral Director
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Dante Of Cremation
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Time Cremation
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804 .
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
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:
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(Name) (Sex)
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(Street) (City) (State) (Zip Code)
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Place culA-
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Nameand add nea living relative 9`'�'me'of person authorizing Lion:
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(Name) (Address)
Relationship to the.-•::; S. Se Alt
Name of Funeral Home "q r eta &say divitAd
IMPORTANT:
I represent that to the best of my knowledge,the er,defibrillat battery,battery pads,power
' cell,radioactive implant or radioactive device in his or her .(Cir •
I certify that I have 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• •• •.v' ed the cremation of said remains as directed,whether such daims or demands are or are not wholly
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'1 ' V., (Address)
(Signature :,"I. of Relative or Legal Representative)-
Signed on this date: gI28(r P
Disposition of Cremated Remains ,
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:.
Mail to
Other arrangements-Please specify: 7Z t Ti 4 T PCIAArtelet-r I ^"" _
If pulverization of cremated remains is requested,check here ✓
Revision:April 18,2007