Chatterton, Loren rl-O`I�!`71C OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorrAy.,E-go-A
Name /-0AF� G/ffq;n R Case #
Date of Cremation
Time Cremation Started Z1'cw1g1M I
Time Cremation Completed T1�o a I ,
Type of Container 4:1z�K G T Qlz-
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:
Loren Walter Chatterton Male
(Name) (Sex)
18 Division Rd Queensbury,NY 12804
(Street) (City) (State) (Zip Code)
who died on 24th day of November 2000
at 18 Division Rd
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Vivian DeLong 18 Division Rd, Queensbury,NY 12804
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowled e, the deceased has or :has no
pacemaker in his or her body. (Circle Onej
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.
61,o /., ,<J 68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address)
(IV, 1v'b fit/
O all vli i...�
(Signature of Relative or Lega\ep. and Address)
Signed on this date: