Loading...
Millington, Ronald . rl-nWN OF QUEENs5BU.WY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name fibly&17 M 11h 1/&;Led Case # Date of Cremation / '-' /<I, ` accx: Time Cremation Started 9( cz" 4/M ► Time Cremation Completed llf� -34 rO Type of Container /W4ffd/9/f il";� A-7G�s,�©f -,f -f�i9� Remarks : Ae ���If 3 "O�/ 1 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: Ronald L. Millington Male (Name) (Sex) (Street) (City) ( State) ( Zip Code') who died on the 15th day of January 2 04 ` at Glens Falls Hospital = Glens Falls New York (Place) (Address) ~ � Name and address of nearest living relative or name -o , pe*A%15 authorizing cremation: = x'`G 0`' Mrs. Marlene Millington - P.O. Box 368, North Creek; New York, f:1'ae"ti0 (Name) (Address) Relationship to the deceased Wife Name of Funeral Home Alexander Funeral Home - 4479 St.ate;8 . $,( A1,�� -Rcivr, NY IMPORTANT: I represent that to the best of my knowledge, theldeceasdd"' ��y has no pacemaker in his or her body. (Circle One) " I certify that I have the full power and authorization to arr'L. e� for the cremation of the remains and to direct the disposition .,; , the cremated remains, that any personal possessions have eitnJr- been removed or may be destroyed, and agree to protect, defend and save harmless Pine View Crematorium from any and 411 claims ani demands for loss or damages which may be made against them by reason of or connected with the cremation of said remains as cted, whether such claims or demands are or tare not wholly grou dless, false or fraudulent. John S. Alexander - 3809 Main St. Warrensburg, NY 12885 }(Witne ) (Address) Marlene Millington - P.O. Box 368, North Creek, NY ( Signature of Relative or Legal Rep. and Address) Signed on this date: January 15, 2000