Miner, Richard rrO l+N OF QUEEVBU-' �
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C iMkk- 7—od
Name /cAgp 4a , /q Case #
Date of Cremation / 1 — 13 —
Time Cremation Started t '-?c 4 f M
Time Cremation Completed A4fl 11m
Type of Container
Remarks :
/9 M
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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:
Richard W. Miner male
(Name) (Sex)
5 New Swamp Rd Hudson Falls NY 12839
(Street) (City) (State) (Zip Code)
who died on 9th day of November 2000
at 5 New Swamp Rd Queensbury NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Phyllis Miner 5 New Swamp Rd, Hudson Falls, NY 12839
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home Garleten FuneralHere 1- a
.- IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (h:a2snoD
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cremation i
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.
? Carleton Funeral Home, Inc. , Hudson Falls ,
(Witness) (Address)
5 New Swamp Rd . , Hudson Falls', NY 128 �;,
( ignature of Relativ or Legal Rep. and Address)
Signed on this date: