VanPelt, Diane •��Jdi.aL�'r;
TOWN OF QUEEM,5BU'�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY. NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name J//' � . L-T Case # < "►�
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Date of Cremation
Time Cremation Started
Time Cremation Completed t -C �M -
Type of Container (�od.PM136Z i 2 !s/r G s:5E02'
Remarks :
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TOWN OF QUEENSBURY
pINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-44476or if no answer
Cemetery
AUTHORIZATION TO CREMATE
The undersigned requcsts and authorizes Pine View Crematorium,
accordance with and of! Female
to' its Rules and Regulations to
cremate the remains o
Female
Diane M. VanPelt
_
(Sex)
(Name)
487 Igerna Rd. , North Creek, NY 12853 (S t at e) (Zip Code
(Street ) (City)
99
who died on
14th d a y of May 19
at Glens Falls Hospital, Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of persc
authorizing cremation :
Thomas E. VanPelt
Same as above
(Name) (Address)
Husband
Relationship to the deceased
Alexander Funeral Home, Warrensburg, NY
Name of Funeral Home
IMPORTANT: the deceased
I represent that to the best of my know
hasone)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the remains ndodiectthishavetIOn Of
er-
the cremated remains, that any personal - possessions r n_
been removed or may be destroyed, and agree to protect , oe e
and save harmless Pine View Crematorium f be m any made an l
against them
and demands for loss or damages which may 9
reds of or connected with the cremation of said remains as
erected, whether such claims or demands are or are not wno :
49roundle , false or fraudulent .
Warrensburg, NY
(Witness ) (Address )
Same as above
(Signature of Relative or Legal Rep. and Address)
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