Langworthy, Nancy 7Oq+N of QUEEVBU-'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Q11)5X/ liyo/ �r— &ZtkZ—
Name CkAWC� Case # �'?CZO
Date of Cremation
Time Cremation Started' g-8r07, �! M
Time Cremation Completed o2� /A
Type of Container /,T.71��f /J „��
Remarks :
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j TOWN OF QUEENSBURY
PINE VIEW CEMETERY �^
CREMATORIUM
Quaker Road, Queensbury, New York 12804
j' Phone (518) Crematorium 745-4477 or if no answer
k
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in
arc ordance with and subjecf to its Rules and Regulations to
cremate the remains of:
Nancy E, Langworthy Female
(Name) (Sex)
I '
63 Dorset Rd. , Brant Lake, N.Y. 12815
r
(Street ) (City) (State) ( Zip Code )
whb died on 24 Th. day of July 19 98
at Glens Falls Hospital, Park St. , Glens Falls, N.Y. 12801
(Place) (Address)
Name and address of nearest living relative or nave of person
authorizing cremation :
Dana Langworthy, Husband, 63 Dorset Rd. , Brant Lake, N.Y. 12815
�! L (Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Alexander-baker Funeral Home
IMPORTANT:
I represent that to the best of ray knowledge, the deceased has or
h s no pacemaker in his or her body. (Circle One)
I ertify that I have the full power and authorization to arrange
fojr the cremation of the remains and to direct the disposition of
th;e cremated remains, that any personal possessions have either
4' be:en removed or may be destroyed, and agree to protect , defend
d an,d save harmless Pine View Crematorium from any and all claims
an;d 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
o ndless, fal e or fraudulent.
Al
4
I i (W t s ) (A ress )
( ignature ot;',`�elativeW Legal Rep. and Address)
Signed on this date : July 25, 1998