Duclo, Helen A. jot j,//,b U �cee�2s �cN(
ritlE VIEW CENIETERY ar,d CREMATORIUM
QUAKER ROAD. Q;i 8)79U 4 Y. EW YORK 12801
(5I8) 793-9777
Funeral Dirictor
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.�I �.�C) Case No.
Dale of Cremation ` Z3—
'1'inM Cremation Started
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'Time Crenkition Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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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:
Helen Agnes Duclo Female
Name Sex
Rt. 300 Box 82 Bomoseen, Vermont 05732
Street City State Zip Code
who died on 21 day of April 19 91,
at Rutland Regional Medical Center, Allen St., Rutland, Vermont 05701
Place) (Address)—
Name and address of nearest living relative or name of person authorizing cremation:
Frances Willis Rt: 30, Box 82, Bomoseen, Vermont 05732
Name Address
Relationship to the deceased Grand-daughter - Executrix
Name of the funeral home Durfee Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or her body. (CIRCLE ONE)
1 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.
i ess J
Signature o IL-1
Relative or Legal Rep.
Address Address
Signed on this :late