Savage, Madelyn '�Y
TOWN OF QUEEVBUj
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director !j' . k-g
Name / " J. ���1 Y �4z Case # 0� 6
Date of Cremat i cn t/—';t'3 `2 t
Time Cremation Started���t� a—
Time Cremation Completed 1��3� P, MN
Type of Container
Remarks :
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1IIWN OF WIFENSDURY
MINE VIF_14 UEMEIE"y
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Qual►er 17n.�►I, I)tip PIISbUI'y, New York 121304 ob, Zi
Phone (519) Crematorium 745-4477 or if no answer
Cemetery 745-4476
fll.)tl Iu I Z/1 t 1 UN to CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
accordance with a►►d su(►Ject to its Rules and Regulations to
cremate the remains ofr
Madelyn Savage Female
(Name )` ------ (Set()
27 Prospect_ St._ Fort Edward_:- _ NY _ _ 12828
(Street ) (City) (State )^` (Zip Code )
who died on 21 day ofJune 19 97
at 27 Prospect St. , Fort Edward, NY
(Place ) If1c1►1► eq� l
Name and address of r►ea►•est 1 ivir►g relative or name of person
authorizing cremationr
Dianne Curtis, 27 Prospect St. , Fort Edward, NY 12828
(Name) inddroun )
Relationship to the deceased daughter
Name of Funeral Home M. R . Kilmer Funeral Home
IMPORTANT3
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 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 arry '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
dire ed, whether s ►ch claims o demands are or are not w olIV
gr rn less, fa/1 �e� frr�►dulen . a
i_t.ness ) (address )
c
(Signature of Relative or Legal Rep. and Address)
Signed on this dater