Baldwin, Leland z01+N of QUEEN,5BUS%
,Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director df'E lr
Name /..�/L.// �� �C7/�� 4J %� C a s e #
Date of Cremat i cn
Time Cremation Started lel:;'t M `
r
Time Cremation Completed - l6 4rm -
Type of Container Q6/I,V,CXJ �j7 D� `�j�,�,�/QV
Remarks :
141"9 N
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TOM OF GUEUPOWWRY
PINE VIEW CEMTOW
CREMTORIUM •
Quaker Road, Quvensbuo-y, New York 12B04
Phone MS) Crematorium 745-4477 or if mo answer
Cemetery 745-4476
AUTHOR I LAT I ON TO CRE"1sFiTE
The undersigned requests and authorizes Pine View Cramaterium, in
occordance witn and subject to its Rules and Regulations to
cremate the remains of:
Leland �. Baldwin NaI ---
(Name) t5ex)
... Ws RtQ. 9N �-W 17$1e
tstrtet) (City) (State) (Zip Cade.)
who died on �3 day of AP"1 lgtjy
at glens Falls Hospital, Glens Falls, NT
tplace) (Address)
Nome arM addrws% of nearest living relative or nose of person
authorizing Cremation:
Michael Dillon, $d.D., Director 10 Railroad P1. , Saratoga 6prins, NY 12.866
(Nome) (Address)
Relationship to the deceased Capital District DSO Director
Na■t of Funeral Home Braver Funeral Nome, Iac.
I i�ORTANT
(sent that to the best of my knowledge, the deceotied has or
his n pae*maker in MIS ar hlrr body. (•Circle Ont)
I certify that I have thr full power ar+d authvrrizativn Zv arrAn9v
for the cremation of the remains and to dirtct the dispu$ttian of
the creeated rewarins, that Any Personal possessions have 91ther
been removed or .ray be destrvyvd, and agree to protect, defend
and save harrsless Pinv View Csrematorius fens any and all Claims
and dova<nds for loss or damages which say be Cade against them by
reason of or Connected with the cremation of said rosdins as
Qirected, whethwr such claims or, drsa►nds are or are not wholly
geeundly false or fr u ant.
tMitnes � t
Director, Capital District DI
(Signs urr of Relative or al Rep. ohd Address
Signed on this date: f `t 7