Davies, Stanley J. jotul'b v llceel2:S tN�-
PINE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSDURY, NEW YORK 12801
(�,18) 798-4726
(518) 793-9777 ./
Funeral Dirictor,/ �®�► o( 2��
Case No.
Dale of Cremation
,ring Cremation Started
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'1'i.me Crern<3t ion completed
.1 Ee of Container
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TOWN OF QUEENSBURY
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PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
J. vies male
Name Sex
5 GreenwaV Drive Queensbury N. Y. 12804
Street City State Zip Code
who died on 3rd day of January 19 90
at Glens Falls Hospital, Glens Falls, New York
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
Dprothea P. Davies 15 Greenway Drive
Name Address
Relationship to the deceased wife
Name of the funeral home 1Re9Pn ;;nrJ nenny. Funeral Service Inc
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker 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, false or fraudulent.
Witness -7� Signature of Relative or Legal Rep.
Address Address
Signed on this date January 4, 1990