Fish, Elsie rl-oW N OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director &rx#AQAC-x
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Name Case Case #
Date of Cremation
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Time Cremation Started
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Time Cremation Completed -rf t
Type of Container
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Elsie Jane Fish Female
(Name) (Sex)
406 Bird Pond Road, North Creek, New York 12853
( Street) (City) (State) (Zip Code)
who died on the 10th day of January 1V 2000
at Glens Falls Hospital Glens Falls, New York 12801
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
Kenneth D. Fish - 406 Bird Pond Road., North Creek, New York 12853
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Alexander Funeral Home - 4479 State Rt. 28, N. River, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased 1IWXXXW
has no pacemaker inJb&,,;_U0W her body. (Circle One)
I certify that I have the full power and authorizat' n to arrange
for the cremation of the remains and to direct the dispodition 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
d' e , whether such claims or demands are or are not wholly
froundl s, false or fraudulent.
John S. Alexander - 3809 Main St'. , VF laurg, NY 12885
(Witness ) (Address)
( Signature of Relative or Legal Rep. and Address')
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Signed on this date: January 10, 2000