Stearns, James �o of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director c&? 4E- `ily
Names S T�fMvS Case # l ��
Date of Cremation /aL _ azz — 07b�
Time Cremation Started .z-g
Time Cremation Completed yt / M
Type of Container�f&IF 0014�-D -51 1 9 ci9�j,FO'�5
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
&
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone:4518) 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 A.Stearns .-_... ... .. __ Male
(Name) (Sex)
50 Farr Lane Queensbury,NY 12804
(Street) (City) (State) (Zip Code)
who died on 22th day of December 2000
at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801
,(Pt,hace (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Debbie Rooks" 58 John St, Hudson Falls,NY 12839
(Name) (Address)
Relat6vihip-to the deceased Daughter
NameibFui�er'bl Home Carleton Funeral Home,Inc.
IMPORTANT:-
I represepf tligf,to the best of my knowledge, the deceased has or has no
pacemaf'6r m 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 prbldct, 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.
0J68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address) L I/
i 1��f �S-k J J�r Sl l�vc� �,j yjL/I
(Signature of Relative or Legal Rep. and Address)
VC L OUP
Signed on this date: Z 2