Walters, Pauline P TO OF QUEES23r(1.0
PINE VIEW CEMETERY AND CREMATORIUM
QlUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745.-4477
Funeral Director MB
Name II Kish,►�12
�,u „�� lJ Case# 51
Date Of Cremati.on 1WvP„"
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Time Cremation Started
Time Cremation Completed
Type of Container ffII ^,/
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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 under(siignedd ` �requests and authorizes Pine View Crematorium,inac/cyo�rddanncee with and subject to its Rules and Regulations to
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Name and iegldre-ss ofcfst 1 41r t�t�GLcS a .101iving relative or name of person 14- ,JW •' pQ . 56C I� t z o3
(Name) (Address) V
Relationship to the decease 56U ,
Name of Funeral Home W l kn
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
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 of or with of said remains TTmains as directed,whether such claims or demands are or are not wholly/
g less,tel fraudulent. 4 iR� b �� / /t L�WS� �� /V • \ '
at,611. _ to
(Signatt)re and Address of Relative or Legal Representative)
/ Signed on this date: J O ( 1 o t o C
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cre remains as follows:
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Mail to .-41 Z-V:"1J� '
3,39, c0.4.1 &L - g , to s-e®
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here K
Revision:January 1,2006