Coolidge, Regina 707+N of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 4!f!h1 C)E- /\/
Name A��//y �.QQ,� �� Case # �d
Date of Cremation
Time Cremation Started , ! M I
Time Cremation Completed `�t 3� //V1 t
Type of Container G �dS� ��p�,`d��r�/'9�•�—�/� T/y.C��9�
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:
Regina Olivia Coolidge Female
(Name) (Sex)
Wesley Health Care Facility Lawrence StrSetatoga Springs,NY 12866
(Street) (City) (State) (Zip Code)
who died on 24th day of February 2000-
at Saratoga Hospital Saratoga Springs,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Clairemarie Coto 10 Beech Street, Hudson Falls,NV� 1190g
(Name) (Address)
Relationshipto the deceased r~! ' N
OAR f'id°AW
Name of Funeral Carleton Funeral Home,Inc."
a Home
IMPORTANT:
I represent that to the best of my knowledge, the deceaseed,;. .-..has,: e:crrm rxo
pacemaker in his or her body. (Circle One) _ -•3 =�= ,'� �su�
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 cremaW&retM1ns.(z ttaVMy
personal possessions have either been removed or may be destrby6d;`iEl iw ree
to protect, defend and save harmless Pine View Crematorium from any and all
claims and demands for loss or damages which may be made aga'inet th6liV '-
by reason of or connected with the cremation of said remain s"as `d.irpcted '
whether such claims or demands are not wholly groundless'-,Ws`e-arfraudialent.
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
J (Witness) J (Address)
10 Beech St . , Hudson Fails , Nv
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Z