Falkenbury, Irving Dr. rrO l+N OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director LfZ ) T/11
Name ffi� �/�� �/� v Case # O
Date of Cremation —
Time Cremation Started �Q
Time Cremation Completed Il f
Type of Container
16 p�1
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, in accordance with
and subject to its Rules and Regulations to cremate the remains of:
Irving Milton Falkenb Male
(Name) (Sex)
Hallmark Nursing Centre Sherman Ave. Glens Falls,NY 12801
(Street) (City) (State) (Zip Code)
who died on 24th day of October 2000
at Hallmark Nursing Centre gherman Aye. ,- Glens Falls , NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Joyce Falkenbury 49 Sheridan Street, Glens Falls,NY,12801
(Name) (Address)
Relationship to the deceased Daughter -
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or .etas ono
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cr%potiop
of the remains and to direct the disposition of the cremated remains, tlia�" ,
personal possessions have either been removed or may be destroyed, •and agree
to protect, defend and save harmless Pine View Crematorium from,any ,aA�1�ll.L
claims and demands for loss or damages which may be made against.11h,q'mL;
by reason of or connected with the cremation of said remains as directed. -d
whether such claims or demands are not wholly groundless, false or fraudulent.
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness (Address)
(Signature of-flelativelr Legal Rep. and Address)
Signed on this date: /6 0