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Jenkins, Helen
rro 74N OF QUEEVBURY PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 / ,�, Funeral Director d �7� Name /��i�.ti/Cl ,�/�l�� S Case # u'?C��' Date of Cremation � —(�'7 — Time Cremation Started r Time Cremation Completed �� © /� /�►� r Type of Container Remarks : r D r.39._19 ,�,/� r ��;�3J9 A'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: Helen Isabel Jenkins Female (Name) (Sex) Fort Hudson Nursing Home Upper BroadYmA Edward,NY 12828 (Street) (City) (State) (Zip Code) who died on 23th day of April 20_J, at Fort Hudson Nursing Home Upper Broadway Fort Edward,NY 12828` (Place) (Address) ;>MO Name and address of nearest living relative or name of person,-auftcrQm�tir;�s: 113 ;,° its4� nozisq Betty Clark M Feeder St., Hudson`F*IIs) 8NIGmsi (Name) (Address) s1: C+niq Relationship to the deceased __ Daughter , c -.G=1r q,d vsm doidw ;u1�r , )t vli�'lw fon �Jis io Name of Funeral Home Carleton Funeral Home,Inc: fs, IMPORTANT: ad I.u,T1 en:u,-nqi IIA .A I represent that to the best of my knowledge, the decea§od no pacemaker in his or her body. (Circle One) b91g9oos I certify that I have the full power and authorization to,tarrange,fGr thew. pwatio8 of the remains and to direct the disposition of the crernated,rem>aine otbakoW R personal possessions have either been removed or may be destroyed, a;-sd agree ' to protect, defend and save harmless Pine View Crematoriufm_:h- -,any ant�it;"S .A claims and demands for loss or damages which may-be made__against then1-U by reason of or connected with the cremation of said remainh°.as'+Itifd'cted; ed whether such claims or demands are not wholly groundless, false or fraudulant. i �; irk .,�:=, :�:`EmSI� •. 68 Main Street P.O.Box 67, Hudson Falls,NY 12.7 9 (Witness) (Address) X iCCCt_,'_L__ ( nature of Aelative or Legal Rep. and Address) Signed on this date: R