Clark, Byron 50tun U uee`2:S ttr
y.
rIPlE VIEW MvICTERY and CREMATORIUM
QL►AKFR ROAD, QUEENSDUIZY, NEW YORK 12801
(518) 798 4 72G
(518) 193-9777
Funeral Dirictor
t1.�mA jig, Case No.
DaLe of Cremation
Tints Cremation Started JC2
Time Cremation Completed
1}1 of Container 7
TOWN OF QUEENSBURY "� 9 ,
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'rhe undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
Byron H. Clark Male
Name Sex
193 Lower Dix Ave. , Hudson Falls, NY 12839
Street City State Zip Code
who died on kpril 24, 1992 day of 19
at Glens Falls Hospital, Glens Falls, NY
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Mr. Donald Clark, Sr. 8026 Myrtle Ave. , Hudson Falls, NY
Name Address
Relationship to the deceased Son
Name of the funeral home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no pacemaker in his
or tier 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
68 Main St. Signs ure o Relat ve or Legal Rep.
Hudson Falls, NY 12839 8026 Dix Ave.
Hudson Falls, NY 12839
Address
Address
Signed on this date