Treulieb, Charles rro q+N OF QUEENB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, '. EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directo - xAXB§: �
Name
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Date of Cremation A —3j— adoo
Time Cremation Started /cZ k3,'5--/ i/14 t
Time Cremation Completed
Type of Container (/9Mk&D
Remarks : /
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TOWN OF QUEENSSURY
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:
Charles Treulieb Male
(Name) (Sex)
27 Bakers Crossing Rd. , Lake george, N.Y. 12845
(Street) (City) (State) (Zip Code)
who died on 28 Th day of Oct. Xy!;X 2000
at 27 Bakers Crossing Rd. , Lake George, N.Y. 12845
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
LTA 72eut,/6, 3 27 3iy«s CG&sS^t�- /ZlD2 /" G604GE ,
(Name) (Address)
Relationship to the deceased WiFd
--�
Name of Funeral Home Alexander Funeral 14cxne, Tnc. -3R09 Main St. , Warrensburg, N.Y. 128E
IMPORTANT:
I represent that to the best of my knowledge, the deceased ROM
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, 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
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wholly
grounc}X ss false or udulent.
;'(Witness ) � (Address)
( Signature of Relative or Legal Rep. and Address )
Signed on this date: 29 Th of October, 2000