Nassivera, Thomas T014N of QUEEVBU-'P%
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 4f 4 1,k-Z�/y
Name ��jCJ/�/9S / 7�11�'��f�Case #
Date of Cremation
Ylla'o
r/�
Time Cremation Started
Time Cremation Compl et edyt/a6 oe / m
Type of Container L /� ,�it����-/1 �✓�'/� � .� 0� �i�.C�.��/
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 TO CREMATE
,he undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains of:
inumei Sex e .
50 North St. Hudson falls, City State
Zip Code
who died on 3rd dayof Feb eb 19 93
at Fort Hudson Nursin Home Forte w
Place Address ——
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Cora Nassivera 50 North St. , Hudson Falls, NY 12839
Name Address
Relationship to the deceased wife
Name of the funeral home Carleton Funeral Home Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has has n acemaker in his
or her body. (CIRCLE ONE)
1 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
cted wheth r such claims or demands are, or are not, wholly groundless, false or fraudulent.
'
S g to
ness e o e a ve or Legal Rep.
Carleeton Funeral Home, Inc. 50 North St. , Hudson Falls, NY 12839
Address Address
Signed on this (late
TOWN OF QUEENSBURY
PINE VIEW CEMETERY °
do
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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
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 cremations
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 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
S gnature of Relative or Legal Rep.
Address
Address
Signed on this date