Sapoo, Kimlung 50tun U uee`2:f a r.
('INE VIEW CEMETERY and CREMATORIUM
QUAKER ROAD, QUEENSQURY, NEW YORK 12801
(518) 798 4 72G
(518) 793-9777
Funeral Dirictor / T
Name. � �i 1 �?�(�9'�� _�'f���'D� Case No. �'cxo ,
UaLe of Cremation
f
Tints CrernaLion SLarted
Time Cremation Completed
'I}jxj of Container c;2/Y r {7�
1 /fQ� 71
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9?77
AUTIIORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and
siibject to its Rules and Regulations to cremate the remains of:
Kimlun Sae oo female
Name Sex
6 McDowell St . , Hudson Falls , NY 12839
Street City State
Zip Code
who died on 10th July 92
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:
Kanungnit O ' Malley , 6 McDowell St Hudson Falls , NY 12839
Name Address
Itelationship to the deceased
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 el her been removed or may be destroyed, and agree to protect, defend and save harmless
Pine Vi w Crematorium, from any and all claims and demands for loss or damages which
may b made against them by reason of, or connected with the cremation of said remains
as dir ted, whether such cl 'ms demands are, or are not, wholly groundless, false or fraudulent.
Witness c z �
68 Main St Signat e o Relat ve gt'�,egal Rep.
son Falls NY 12839 6 McDowell St
Address Hudson Falls , NY 12839
Address
Signed on this date