Tucker, Donald rrOq4N OF QUEEVBU9 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Directorx /y
Name PTI*flyCp ���,�� Case # ��
Date of Cremation—
Time Cremation Started 4!1(;Zd h/''AA
r
Time Cremation Completed //ta fg)o 119" 'YI�n
Type of Container G er�,�;Q/���
Remarks :
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Zl !�3�19 /Al
1/ - ' 4
TOWN OF QUEENSBURY ` 3
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,
accordance with and subject to its Rules and Regulations tc
cremate the remains of :
Donald J. Tucker Male
(Name) __. (Sex)
39 Eldridge Rd. , Queensbury, N.Y. 12804
(Street ) (City ) (State) ( Zip Code )
who died on 21 St. day of March Z090
at Gd!ens Fall Ho vital , Park St. , Glens Falls N.Y. 12801
(Place) (Address )
Name and address of nearest living relative or name of persc^
authorizing cremation :
Wi 1 ford F Ttt kPr- 54 Aviation Rd. , p nsbul:y. N.Y. 12904
(Name ) (Address)
Relationship to the deceased Brother
Name of Funeral Home— Alexander Funeral Home
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 , defenc
and save harmless Pine View Crematorium from any and all cla,. ms
and demands for loss or damages which may be made against them r�
reason of or connected with the cremation of said remains as
directed, whether such claims or demands are or are not wnol '
groundless, false or fraudulent .
1:. �✓��� 5048 State Rte 9, Chestertown, N.Y. 12817
(Witness ) --� (Address )
r d �2 a?,liL 39 Eldridge Rd, Queensbury, N.Y. 12804
(Signature of Relative or Legal Rep. and Address)
Signed on this date : 6/22/99