Monroe, Gwendolyn rrO WN OF QUEEVBU-'kY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director. &) �dlfk)5 Tes
Name Case Case # S
Date of Cremation
Time Cremation Started lei
Time Cremation Completed 1dcn Fj-M
Type of ContainerinrZ—k,690
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:
Gwendolyn Grace Monroe Female
(Name) (Sex)
Fort Hudson Nursing Home Fort Edward,NY 12828 12828
(Street) (City) (State) (Zip Code)
who died on 4th day of January 00
at Fort Hudson Nursing Home Upper Broadway Fort Edward,NY 12828
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Daniel R.Monroe Jr. 6 BoulevardHudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Carleton Funeral Home,Inc. _
i
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or 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 not wholly groundless, false or fraudulent.
` (Witness)..._.. (Address)
-------- - Sig use of Re -We or Legal Rep. and Address)
Signed on this date: 006