Francis, Don l OWN OF UUEENSbURY
11 I NE VIEW CEMETERY
a
U11EMATUR I UM
Qual►er floacl, (]uee►►sbury, New York 12a04
Phone (5119) Crematorium 745-4477 or if no answer �tf
Cemetery 745-4476
nuT110R I mT ION 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 :
Don E. Francis M
(Name) (Se►s)
16 Boyl)rston St. Glens Falls NY 12801
(Street ) (City) (State) (Zip Code)
who died on 31st ___day of August 19 96
at Albany Veterans Hospital, Albany, NY
(Place) (address )
Name and address of nearest living relative or name of person
authorizing cremations
David E. Francis, S Kvale Lane, Hudson Falls, NY 12839
(Name) (Addroaas
Relationship to the deceased son
Name of Funeral Home M. B . Kilmer Funeral Home
IMPORTANT3
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 .
(WL"ess ) (Address )
(Signature of Relative or Legal Rep. and Address)
Signed on this dates