Lesson, Henrietta TOWN OF F QBZ1T
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,UfPdEhi/fr
Name ikCAR/Fri/9 Le5304Case # ylq
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Time Cremation Started ;2i fg ,isA
Time Cremation Completed !D r / ) tIVl '
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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:
Henrietta Lesson Vamp La_
(Name) (Sem)
17 Davern Drive Lake T,117.Prt1e
NY 12816
(Street ) (City) (State) (Zip Code)
13 November 19 97
who died on day of
at Glens Falls Hospital, Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
David Lesson 17 Davern Dr. , Lake Lu7erne. NV 1 �A�
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Brewer Funeral urn, T11C
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no p er)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 or demands are or are not wholly
groundless, ' fa se r fr ud ent. ,/
iL)
C6771
(Addres ) / / )
/IA
(Signature of Relative or L' gal Rep. and Ad 'ss)
Signed on this date: ��