Porter, Ethel OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director l?Le 70—
Name )C �2Z= Case # �cJ
Date of Cremation — c�
Time Cremation Started $'cr a,�/l I M
Time Cremation Completed
Type of ContaineryGj7—/y CI�5,jj-,E'T" !S %, /gS,C— �FTrj,�r
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:
Ethel Jane Porter Female
(Name) (Sex)
27 Court Street, Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
who died on 16 day of July, 2000
at Glens Falls Hospital, 100 Park St. , Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Roder J. Porter, 30 Delaware Ave. , Hudson Falls, NY
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Carleton Funeral Home Tnc
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has7n )
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.
30 Delaware Ave. Hudson Falls NY
(Witness) (Address)
,J 68 Main Street Hudson Falls NY
(Signature of Relative or Legal Rep. and Address)
Signed on this date: _July 17., 9000