Rupracht, Mildred rrO%N OF QUEEVBUXY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director G,4911)6� rllt
Name l��17�,�U �(,'� ,� / � Case # �j
Date of Cremation 67- aO,�7 f
Time Cremation Started Zz'�-f- Z2—/A t
Time Cremation Completed % a6 P"m )
Type of Container
Remarks :
/Jc�s•�� 1��11f1 I
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:
Mildred S. Rupracht female
(Name) (Sex)
12 Greensway Dr. Queensbury NY 12804
(Street) (City) (State) (Zip Code)
who died on the 18th day of February 2001
at Indian River Nursing Home, Granville, NY 12832
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Philip C. McIntire, 1 Washington St, Glens Falls, NY 12801
(Name) (Address)
Relationship to the deceased attorney
Name of Funeral Home —GarretenFune-a'��Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or C!h� s no
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 reaso of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
,Z,(( - 68 Main St , Hudson Falls , NY 12839
(Wit
Vess) %(Address)
1 Washington St, Glens Falls , NY 12801
Signature of Relative or Legal Rep. and Address)
Signed on this date: 2/20/01