Davis,James TOWN OF QUEEVBUJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Name /��S � LS Case #
Date of Cremation
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Time Cremation Started o® r 1 9
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Time Cremation Completed / r-�
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TOWN OF RUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Phone (518) Crematorium Quaker
Road,
qg 47 nsbury, New York 12904
26 or if no answer Cemetery 793-9?77
AUTIIORIZA't'lie undersigned requests and authorize T
s Pine View TCemaBoriAumE in acc'
subject to its Rules and Regulations to cremate the remains of: ordance 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 her body. (CIRCLE ONE)
I certify that 1 have the full power and authorization to arrange for the cremation of
remains and to direct the.disposition of the cremated remains, that an the
essions
have either been removed or may be destroyed, and agree to protect, defend and save armless
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 Relat e- or Legal Rep.
Address
Address
Signed on this date
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
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:
James Ernest Davis Male
Name Sex
2 Kidder Lane Glens Falls NY 12801
Street City State Zip Code
who died on 17th day of July 19 93
at Glens Falls Hospital Park St. , Glens Falls, NY
Place) (Address) —'—
Name and address of nearest living relative or name of person authorizing cremation:
Carol Davis 48 Martindale Ave. , Hudson Falls, NY
Name Address
Relationship to the deceased sister
Name of the funeral home Carleton Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 69:n:0)a
cemaker in his
or tier body. (CIRCLE ONE)
1 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 48 Martindale Ave. , Hudson Falls, NY
Address
Signed on this (late July 20, 1993