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Jolly, Dorothy 50tun v ueeni urr. I'IPlE VIEW CEMETERY and CREMATORIUM QUAKFR ROAD. QUEENSDURY, NEW YORK 12801 (518) 798 4 726 (518) 793-9777 Funeral Dirictor ��,� ,��� Case No. UaLe of Cremation Tinw, Cremation Started 9f/ } �//✓1 Time Cremation Completed '1}r of Container 14, d, 1� a]7 /S / ��5,� ©�' �j7,c� �Y : uy 4C7 /� /►� i 19, ins► _4 & 14 'e d ",41m ) ,fI i9lkl ly- oZ D6 TOWN OF QUEENSBURY PINE VIEW CEMgTERY do CREMATORIUM Quaker Road, Queensbury, New York 12804 Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777 AUTIIORIZATION TO CREMATE 'fhe undersigned requests and authorizes Pine View Crematorium, in accordance with and subject to its Rules and Regulations to cremate the remains of: Name Sex Street City State Zip Code who died on day of 19 Fit Place Address —— Name and address of nearest living relative or name of person authorizing cremation: Name Address Relationship to the deceased Name of the 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) 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 (Signature of Relative or Legal Rep. Address Address Signed on this date TOWN OF QUEENSBURY w PINE VIEW CEMETERY -70� 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 oft Dorothy Jolly female Name Sex 207 Dix Ave . , Hudson Falls NY 12839 Street %Cit y State Zip Code who died on 18th day of Sept . 1992 207 Dix Ave. , at Hudson Falls, NY Place Address 1 —_ Name and address of nearest living relative or name of person authorizing cremation: Mrs . Ruth C1ark, . Myrtle Ave. , Hudson Falls , NY 12839 Name Address Relationship to the deceased executrix Nance of the funeral home Carleton Funeral Home Inc. IMPORTANT: I represent that to the best (if 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 t remains and to direct the disposition of the cremated remains, that anposses I on 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. 44e�ss gnature o Relat ve or Legal Rep. Carleton Funeral Home, Inc. Address 1 s NY Address Signed on this date