Clarke, Felicia T074N OF QUEEN*15BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director e,I'7�j 0
Name
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Date of Cremation
Time Cremation Started U/ �r��i7l i►! /
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Time Cremation Completed��l /�
Type of Container ���/T .D 5,0d1?D 1,572, c zl��,,c- 0/1=- T/y,F P, 9,/
Remarks :
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTHORIZATION
e TwTO BThe undersigned requests and authorizes Pine Crematorium, in accord
subject to its Rules and Regulations to cremate the remains of: ance with and
Felicia Clarke
female
Name
- Sex
117 Hunter St. Glens Falls NY
Street 12801
City State �Zipode
who died on 3rd
day of Feb. 19 93
at Glens Falls Hospital , Glens Falls, NY
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
Mrs . Judith L ke, RD 1 Box 308 , Tripoli Rd Hudson Falls,
Name Address NY
Relationship to the deceased daughter
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)
1 certify that I have the full power and authorization to arrange for the cremation of th
remains and to direct the.disposition of the cremated remains, that an e
ssions
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
m e made against them by reason of, or connected with the cremation of said remains
dir c d, w er such claim or demands are, or are not, wholly groundless, false or fraudulent.
Witness
XAS�gn
ture o Rel t ve or Legal Rep.
Carleton Funeral Home. RD1 Box 308 . Tripoli Rd
Address Address
Signed on this :late `7 ( 5 3
TOWN OF QUEEN38URY
PINE VIEW CEMETERY
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 Sex
Street City State Zip Code
who died on day of 19
at
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:
1 represent that to the best or my knowledge, the deceased has or has no pacemaker in his
or tier body. (CIRCLE ONE)
I certify that 1 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 o Relat ve or Legal Rep.
Address Address
Signed on this (late