Legler, Dorothy ro WN of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �V� 4'� - `
Name j�-a-� rl 4' t kF-& LZQ Case #i
Date of Crematicn 1 3 - C�
Time Cremation Started 1v _r
Time Cremation Completed
Type of Container eo -
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:
Dorothy- Mae LeAler Female
(Name) (Sex)
127 Luzern Rd. Aueensbury, NY 12804
(Street) (City) (State) (Zip Code)
who died on 2nd day of November 99
at 127 Luzern Rd. , Queensbury, NY 12804
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs. Alsey Pouliotte 127 Luzerne Rd. Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased Sister-in-Law
Name of Funeral Home GN9AV1J TXNJ9 s�1
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or Caso
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,
wh ther such claims or demands are not wholly groundless, false or fraudulent.
f �l� 68 Main St. , Hudson Ealls, NY 12839
(Witness) (Address)
127 Luzerne rd. , Queensbury, NY 12804
.( nature of Relative or Legal Rep. and Address)
Signed on this date: 11/2/99