Hagan, James T07+N OF QUEEMB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Name- /�{, ,�j1� Case #
Date of Cremation ;Z06%=7
Time Cremation Started j// A 'r Mt
Time Cremation Completed I a-e sa T/Ir 1 f
Type of Container
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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:
James Wells Hagan male
(Name) (Sex)
233 Cleverdale Rd Town of Queensbury NY 12804
(Street) (City) (State) (Zip Code)
who died on 24th day of August 2000
at 233 Cleverdale Rd. Queensbury
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
my n Hagan, 233 Cleverdale Rd. , Cleverdale, NY 12820
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home ,
IMPORTANT: -k-"
I represent that to the best of my knowledge, the deceased has orQ-1
as no
pacemaker in his or her body. (Circle One)
1 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
7by r ason of or connected with the cremation of said remains as directed,
whe her such claims or demands are not wholly groundless, false or fraudulent.
68 Main St , Tpason Falls , NY 12839
Witness) (Address)
233 Cleverdale Rd, Cleverdale, NY
(Signature of Relative or L I Rep. and Address) 12820
Signed on this date: