Wert, David TO q+N OF QUEEVBU Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director A-LKj XO — 9
Name it,,�K-r Case #
Date of Cremation
Time Cremation Startedi� % M
Time Cremation Completed
Type of Container
Remarks :
MAi N ,C3tJ/�i�l�R oX '`;' ' //)/ 1
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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 E. Wert Male
(Name) (Sex)
11 Fourth Ave. Unit 2 Warrensburg , New York 12885
(Street ) (City ) (State) ( Zip Code )
who died on 11th day of January 19 99
at Tri County Health Care Facility North Creek, New York 12853
(Place) (Address)
Name and address of nearest living relative or name of perscm
authorizing cremation :
Mrs_ Ruth T. Wert 11 Fourth Ave. Unit 2 Warrensburg, New York 12885
(Name ) (Address)
Relationship to the deceased Wife
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of ray knowledge, the deceased XXcXXXX(Xx
has no pacemaker in his )PrQ'XXN)tr 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 eitner
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 L-`
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not
groundless, false or fraudulent.
(Witness ) , (Address )
( ignature of Relative or Legal Rep. and Address)
Signed on this date : /— g-