Baker, David 2r0RN OF QUEEN,5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A- ' \
Name 3)RVt"d Case # !y
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Containers
iZ a Jl r-c) s�-
Remarks :
Aii4i N
UCH E
hlr nn
1/ 11 M ,
r
TOWN OF QUEENSBURY /
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:
David A Raker Male
(Name ) _ (Sex)
11 Staple Street Glens Falls New York 12801
(Street ) (City ) (State) ( Zip Code )
who died on 11th day of November 1998
at Home 11 Staple Street Glens Falls, New York 12801
(Place ) (Address)
Name and address of nearest living relative or name of perscn
authorizing cremation :
K. Renee Baker 11 Staple Street Glens Falls, New York 12801
(Name ) (Address)
Relationship to the deceased wife
Nave of Funeral Home Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased V)W%XVXX
bas no pacemaker in his XYr )0XX* 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
r song of or connected with the cremation of said remains as
directetd, whether such claims or demands are or are not wholly
groundle s, false or fraudulent .
( ness ) (Address )
( ignature of Relative or Legal Rep. and Address)
Signed on this date : November 11. 1998