Worth, Gloria TOWN OF QUEEN B UP..y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director , 2�g
Name � / I j Case #
Date of Cremation Z—
Time ,Cremation Started7f,6 f7 1/yI�
Time Cremation Completed°)' 4 r p w
Type of Container "4/-i-BL sl azgzr p l 5 ri c:" t7
Remarks :
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TOWN OF QUEENSBURY JPINE VIEW CEMETERY& L:50
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:
Gloria Worth Female
~ (Name) (Sex)
137 Franklin Street Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
who died on 4th __ day of July, 1999 _
at Glens Falls Hospital . Glens Falls, NY _
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Robert 0. Worth 137 Franklin Street Hudson Falls, NY 12839
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home _ -
IMPORTANT: --�—
I represent that to the best of my knowledge, the deceased has or as 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
by r ason of or connected with the cremation of said remains as directed,
whe her such claims or demands are not wholly groundless, false or fraudulent.
C68 Main Street, Hudson Falls, NY
(Witness) (Address)
U4 Q A,;r 0 LCJ fie..,
ignature of Relative or Legal Rep. and Address)_
Signed on this date: