Marquette, Lora TOWN of QUEEVBU-Ry
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_
Name 10919. lnl/ lS (X����� Case #_p�
Date of Cremation
r �
Time Cremation Started. r/o2 t A0 /�`/0 j
Time Cremation Completed R i A41
Type of Container G/9/ /sT
Remarks :
lI l Cz 'OZ P,
TOWN OF RUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
CREMATE
The undersigned requests and authorize AUTHORIZATION
s Pi e View TCrematorium, in accor
subject to its Rules and Regulations to cremate the remains of: dance with and
Name
Sex
Street Cit
y 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:
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 ,;ature of Relat ve or Legai Rep.
Address
Address
Signed on this date
TOWN OF QUEEN38URY
PINE VIEW CEMETERY �l
do
CREMATORIUM
Quaker Road, Rueensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
AUTUORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and
subject to its Rules and Regulations to cremate the remains off
Lora White Marquette female
Name Sex
Apt7F Earl Towers, Hudson Falls, NY 12839
Street City State Zip Code
who died on 12th dayof
.i1ma 19 q_q
at Glens Falls Hospital, Glens falls, NY
Place Address ——
Name and address of nearest living relative or name of person authorizing cremations
Mrs. Carol Daly Box 222, RD 4 Ohio Ave. , Queensbury, NY 12804
Name Address
Relationship to the deceased
niece
Name of the funeral home Carleton F m ral Hom Tnr
i M PORTA NT:
I represent that to the best of 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 the
refrains 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 Rela o
al Rep.
arl ton Funeral Home Inc. Ohio Ave.
Address Queensbur Address NY 12804
Signed on this date