Petit, James T(IWN OF UUEENSUURY �~ _-
11INE VIEW CEMETERY
I;I1EM11 f Uti I UM
Uualiar• litlact, Ilueensbur-y, New York 1eAO4
Phone (516) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTttOR I Zf1T 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 :
James S. Petit Male
(Name) (Seat)
RD 1 Fort Miller Road, Fort Edward, NY 12828
(Street ) ^(City) (State) (Zip Code)
who died on 25th ---_ - -day of December 19 96
at Glens Falls Hospital, Glens Falls, NY 12801
(Place) (address )
Name and address of nearest living relative or name of person
authorizing cremation :
Mary Major
(Name) (Addrous )
Relationship to the deceased niece
Name of Funeral Home M. B . Kilmer 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
grogndless, false or fraudulent.
(Wl.)-ness) (Address)
( gnature f Relative or Legal Rep. and Address)
Signed on this dates