Petrikas, Jon OF QUEEVBUS�.Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (2hWZ&- 4?-1
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Date of Cremation �c�o2'_N
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Time Cremation Started /a1z '
Time Cremation Completed c2-l-4S- - 2fZA I
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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
AUTIIORIZA71ON 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:
Jon Anthony Petrikas
----------------
Name
Sex
6 Cashmere Dr. Ft. Edward, NY 12828
Street
City State Zip Code
who died on April 21, 1993
day of 19
at Glens Falls, NY (Glens Falls Hospital)
Place Address
Name and address of nearest living relative or name of person authorizing cremation:
Mrs. Linda Barber, RD 2, Box '2872, Beckwith Rd. , Whitehall NY
Name Address
Relationship to the deceased
Sister
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 t
remains and to direct the.disposition of the cremated remains, that an he
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
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.
C4
Witness 8 gnature o Relat ve or Legal .
68 Main St. RD 2, Box 2872 p
Address
Address
Signed on this date
April 21, 1993
TOWN OF RUEENSBURY
PINE VIEW CEMETERY
do
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or If no answer Cemetery 793-9777
AUTHORIZATION TO CREMATE
'f Ise 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 cremations
Name Address
Relationship to the deceased
Name of the funeral home
IMPORTANT:
I represent that to the best (if 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) S gnature o Relat ve or Legal Rep.
Address
Address
Signed on this date