Barker, Walter , rOq+N OF QUEEN-,,,5Bu-qzy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director d 4)E)(19ZV D
Name �tJi�-� � ,�i9�(� / Case #
Date of Crematicn
Time Cremation Started � rv� j'� l �
Time Cremation Completed -
Type of Container
Remarks :
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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,
accordance with and subject to its Rules and Regulations to
cremate the remains of:
Walter Barker Male
(Name) __. (Sex)
3879 Main St. , Warrensburg, N.Y. 12885
(Street ) (City) (State) ( Zip Code )
who died on 23 Rd. day of April 19 99
at Glens falls Hospital, Park St, Glens Falls, N.Y. 12801
(Place ) (Address )
Name and address of nearest living relative or nave of perscr
authorizing cremation :
Mrs. Georgiana� Barker, 3879 '4ain St. , Warrensburg, N.Y.- 12885-
(Name ) (Address )
Relationship to the deceased Wife
Nave of Funeral Home Alexander Funeral Home, 3809 Main St. , Warrensburg, N.Y. 12885
IMPORTANT:
I represent that to the best of my knowledge, the deceasedX
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 , defenc
and save harmless Pine View Crematorium from any and all clams
and demands for loss or damages which may be made against them ^ ,
j(directe
of or connected with the cremation of said remains as
, ether such claims or demands are or are not wno ! ' ,s , false or fraudulent .
GcJy�ls�3unti ,�Lf.
(Witness ) (Address )
3879 Main St. , Warrensburg, N.Y. 12885
ignature of Relative or Legal Rep. and Address)
Signed on this date : 'April 23, 1999