Hayes, Selina TOWN OF QUEEN `Ll-'ky
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/ - /►/7/�U � v 'S'd 1v
Name 5��111yt �/97 Case # 6�
Date of Crematicn
/ y
Time Cremation Started ! lia� /9/&I I
Time Cremation Completed
Type of Container 7-11 vZ �� I� ,)
Remarks :
A141 N /f A. �//✓1'
TOWN OF QUEENSBURYSCJ
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
AUTHORIZATION 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 :
Selina E. Hayes Female
(Name) _ (Sex)
91 Library Ave. Warrensburg New York 12885
(Street ) (City) (State) ( Zip Code )
who died on 24th day of October 19 98
at Glens Falls Hospital Glens Falls, New York
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Frederick I. Hayes 91 Library Avenue Warrensburg, New York 12885
(Name ) (Address)
Relationship to the deceased Husband
Name of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased XtU0)6kX
has no pacemaker in jXgX%XXXX 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 any personal possessions have either
been removed or may be destroyed, and agree to protect , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them by
re of or connected with the cremation of said remains as
d rect d whether such claims or demands are or are not wholly,
round ss, false or fraudulent .
UA?(16-✓jQ)e6 ,V Y.
(Witness ) (Address)
)<
(Signature of FVelative or Legal Rep. and Address)
Signed on this date : October 27, 1998