Floyd, Hubert R. 50tun OlQueenjlttr�-
rlrlE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENCQURY, NEW YORK 12801
(518) 798 4 726
(5I8) 79:3-9777
Funeral Dirictor ��f-
I1•'111l? A &Zhk7rrZ6 Case No. /lel,
Dale of Cremation
Tinr Cremation Started �j �QQ �/V)
Time Crewition Completed
1}E of Container
Lentilr.ks //✓ �1��?11/_� AI Azz
i/ /1
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
d�
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:
Name E
Sex
Nursin Centre eensb NY 12804
Street City State
Zip Code
who died on loth day of kpril 19
92
At. pine View Crematorium Town of Queensbury. NY
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Mr Lois Flo d Tri oli Road Fort Ann NY 12827
Name Address
Relationship to the deceased wife
Name of the funeral home Carleton Funeral Home In
IMPORTANT:
I represent that to the best of my knowledge, the deceased has r has no acemaker 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.
ea,
Witness 4Slg&n=Wtur_eo Relat a or egal Rep.
Hudson Fa_ll__s , NY - West Fort Ann ,- NY
— Address Address ✓
Signed on this (late April 11, 1992