Barot, Gertrude 70 g4N OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
1
Funeral Director C,
Name GE „tU r, 1 ,r ��Rn� Case #
Date of Cremation 2 -
Time Cremation Started `/ - /-.
Time Cremation Completed
Type of Container t
Remarks :
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I
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:
Gertrude Lillian Barot Female
(Name) (Sex)
140 Nain St. Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
who died on 30th day of October 99
at Glens Falls Hospital 100 Park Street Glens Falls, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Kathy Meade 34 Mettowee St. , Granville, NY 12832
(Name) (Address)
Relationship to the deceased friend/executrix
Name of Funeral Home Cle#a�n Funeral {�o�e In,�.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or Chas 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 not wholly groundless, false or fraudulent.
V
- �-� Carleton Funeral Home, Inc
(Witness) (Address)
34 Mettowee St. , Granville, NY 12832
(Signat(ire of Tielative or Legal Rep. and Address)
Signed on this date: (LD�3r/9C1