Carma, Jabera OF QUEENs5BUSy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director /41P
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Time Cremation Completed LV` '
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TOWN OF QUEENSDURY
PINE VIEW CEMETERY
R
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:
JABEV CARMA MALE
(Name) (Sem)
6 GROVER AVE. SOUTH GLENS FALLS, NY 12803
(Street ) (City) (State) (Zip Code)rin
who died on day of !�A Q 19�_
at
(Place) (Address
Name and address of nearest living relative or name of person
authorizing cremation :
JOANNE CARMA, 7411 WOODROWILSON DRIVE, LOS ANGLES, CA 10046
(Name) (Address)
Relationship to the deceased DAUGHTER
Name of Funeral Home M.B. KILMER FUNERAL HOME, 136 MAIN ST. SGF, NY
IMPORTANT:
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 1 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 by
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
groun ss, false' or fraudulent.
( ass) (Address )
(04gnature of elative or Legal Rep. and Address)
Signed on this date : Lj, l ? � 1j