Balch, Chester TORN OF QUEEN4,5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � �
Name 6117J. i�- /l ��/7 Case #
Date of Cremation 11 `rCz-3 1
Time Cremation Started �! /lQ f t
Time Cremation Completed
Type of Container
Remarks :
A1i41 N ,d�Jl�i�l�R o�! /��` 1 y9 /M
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 :
Chester Balch Male
(Name ) -- (Sex)
Trout Brook Rd. , Olmstedville, New York 12857
(Street ) (City) (State) ( Zip Code )
who died on Nov. 20 day of Nov. 19 98
at Glens Falls Hospital, Park St. , Glens falls, Warren Co. , N.Y. 12801
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Mr. Vernon A. Balch, Main St. , Minerva, N.Y. 12851
(Name) (Address)
Relationship to the deceased Brother
Name of Funeral Home Alexander Funeral home
IMPORTANT:
I represent that to the best of my knowledge, the deceased NAXXX�Xr
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 any 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 C
reason of or connected with the cremation of said remains as
eted, whether such claims or demands are or are not wholly
ess, false or fraudulent .
Lv��S'j �
(Witness ) (Address )
Vernon A. Balch, Main St. , Minerva, N.Y. 12851
(Signature o Relative or Legal Rep. and Address)
Signed on this date : Nov. 21, 1998