Austin, Jennie OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director rkr,e'tcr
Name Case# aO
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Date Of Cremation
Time Cremation Started i� ' .2y 11
Time Cremation Completed a (to �►1
Type of Container C'�rAorkfj IF r Cc
5d
Remarks
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Town of Queensbwy
Pine Yew Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Aldhortzation to Cremate
The undersigned requests and autwizes Pine view Crematorium,in accordance with and subW to its Rules and Reguietions to
cremate the remains&..
Jennie Mae (McIntyre) Austin F
(Name) (SOX)
136 Myrtle Ave Hudson Falls NY 12839
(Street) 0 5/0 4/2 0 0 6 (City) ( ) (Zip Code)
who died on day of 20
Residence Kingsbury �Y
at
( ) (dress)
Name arid address of nearest living rn or name of person eutwrbk g crynation:
Jennie Smith 136 Myrtle Ave
(Name) (Address)
Niece
Relations"to the deceased
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:I represent that to the bell of my lotowledge,the deceased(has)or(has no)pacemaker,deftiMaton or any other battery operated
device in his or her body. (Cide One)
I terrify that I have ful power and aulhortzadon to arrange for the er smation of the remains and to direct the disposition of the
cremated remains,then any persona!posseselons.henna either been removed or may be destroyed,and agree to protect,defend and
save hermiese Pine View CremeWfkxn from any and aN claims and denrrands for loss or damages which may be nude against them
by reason of or connected with the aerr aWn of said remains as dinsmd,wheaten such daims or demands are or are not w h*
grcxxdMw,false or frauduient.
t '
( S)
q%natm and Address of Relative or Legal Representative)
Signed on Oft date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the aemraled remains as foibW$--
MaN to
Other arrangements-Please specify:
if puwaraarion of cremated remains Is requested,check here XX
Revision:January 1,2006