Broderick, Dorothy own o aeenj urn
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12801
(518) 798-4726
(518) 793-9777
Funeral Dirictor
Name /�'!� 420 R� �/ �/!®��C /Cl� Case No. aZ
Date of Cremation
Time Cremation Started
Time Cremation Completed l0 r,3� fj ,
Type of Container a.,41m eB fry D2/✓o' C , 5-"'c- e/C
Remarks Ndl-ll✓ 160R/Sl�/E' eAl
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al
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P.O. Box 163, Ellenburg Depot, New York 12935
AUTHORITY TO CREMATE
(This Authority signed by the proper relative or legal custodian of deceased, together with
Burial Permit, must be filed at th. office of Whispering Maples Memorial Gardens Inc., before
cremation may take place.)
I hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains cof: / aFemale
ElMale
(NAME)
(STREET-CITY-STATE-ZIP CODE)
who died on the �Q day of /04y 19—lu, at the age of
I represent that, to the best of my knowledge, the deceased has no pacemaker in his or
her body.
DISPOSITION OF CREMATED REMAINS
hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if
necessary, and to dispose of the reins as follows:
Mail to• >.y.5 V .� C '
/) WUNERAI DIRECTOR OR FAMILY)
(ST -CITY-STATE-ZIP CODE)
Other Arrangements- R
(PLEASE SPECIFY)
I certify that I have full power to give the above Authority to Cremate and to direct the
the above Disposition; and I agree to protect, defend and save harmless Whispering Maples Mem—
orial Gardens Inc. and the Funeral Director from any and all claims and demands for liabilities,
losses and/or damages which may be made against them, or either of them, by reason of, or
connected with, any action taken by them under the above Authority to Cremate and,'or Dis—
position granted and irected by me, whether such claims or demands are or are not groundless,
false or froudulen �I
TNESS SIG URE OF RELATIVE OR LEGAL REP.
t AtlFed Vim £X>!CU�Oy"
�j RAL DIREC OR RELA" ION TO OF-CEASED OR AUTHORITY TO SIGN
' !/ t/
DR S DDRE,S
Sr l/ . 19--ll-,L-
Jy7QQ
Note: All Cremains are returned in a plastic bag in a cardboard box unless other arrangements are made.
Important: The Funeral Director should make adequate inquiries of the deceased's medical
doctor and relatives and any hospital involved to assure that deceased has no pacemaker im-
planted in his or her body. If any pacemaker was implanted, it must be removed before the body
is delivered for cremation.
P.O. Box 163, Ellenburg Depot, New York 1 2J35 /
AUTHORITY TO CREMATE
(This Authority signed by the proper relative or legal custodian of deceased, together with
Burial Permit, must be. filed at th,. office of Whispering Maples Memorial Gardens Inc., before
cremation may take place.)
I hereby request and authorize Whispering Maples Memorial Gardens Inc. to cremate the
remains of•
f2 Female
,�-�:�_ ,,, l �t,�-1•z�.�, ❑ Male
f (NAME)
(STREET-CITY-STATE-ZIP CODE)
who died on the day of __,I41
19 r`', at the age of
I represent that, to the best of my knowledge, the deceased has no pacemaker in his or
her body.
DISPOSITION OF CREMATED REMAINS
I hereby direct Whispering Maples Memorial Gardens Inc. to pulverize the Cremains, if
necessary, and to dispose of the remains as follows:
Mail to:
( UNERAL DIRECTOR OR FAMILY)
($ -CITY-STATE-ZIP CODE)
Other Arrangements-
(PLEASE SPECIFY)
I certify that I have full power to give the above Authority to Cremate and to direct the
the above Disposition; and I agree to protect, defend and save harmless Whispering Maples Mem—
orial Gardens Inc. and the Funeral Director from any and all claims and demands for liabilities,
losses and/or damages which may be made against them, or either of them, by reason of, or
connected with, any action taken by them under the above Authority to Cremate and,'or Dis—
position granted and directed by me, whether such claims or demands are or are not groundless,
false fraudulent ;
T S` SIGNATURE OF RELATIVE OR LEGAL REP.
lJl A TREC-r(5fR'
RELATION TOJOECEASED OR AUTHORITY TO SIGN
)IRE s /ADDRESS// VC
Note: All Creynq)psmre returned in a plastic bag in a cardboard box unless other arrangements are made.
Important: The Funeral Director should make adequate inquiries ,of.the deceased's medical
doctor and relatives and any hospital involved to assure that deceased has no pacemaker im—
planted in his or her body. If any pacemaker was implanted, it must be removed before the body
is delivered for cremation.
Name Case Number
Date of Cremation ' 19
A.M.
Time Cremation Started P•M•
A.M.
Time Cremation Completed P•M•
Type of Container
Remarks:
Signature of Operator