Rowell, Ethan rrnWN OF QUEENB 21.OKY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
E o �
Name Case F31
Date of Cremation 0 0
Time Cremation Started
Time Cremation Completed
Type of Container "3 ,073 t( c yt5 igl= al=
Remarks : 0CZ-3
SCE 1� /-�1
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TOWN OF QUEENSBURY
' PINE VIEW CEMETERY
do
CREMATORIUM
:Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Ethan Cole Rowell male
(Na Sex
29 EliZahth S_t.d..,...Queensbury, NY 12804
Street '-°-�� ' .. Wit
Y State Zip Code
who �'•dim-arf ------- the 5th day of June 2001
at -"'` - Glens Falls Hospital , Glens Falls , NY 12801
Place Address ——
i
Name and address of nearest living relative or name of person authorizing cremation:
i
RiCRY Rowell , 29 Elizabeth Lane, Queensbury, NY 12804
Name Address
Relationship to the deceased
father �
Name of the funeral home
Carleton Funeral Home Inc �
IMPORTANT:
1 represent that to the best of my knowledge, the deceased has o h s no pacemaker in his
or tier body. (CIRCLE ONE)
i
I certify that I have the full power and authorization to arrange for the cremation of the
have either been removed or may be destroyed, and agree to protect, defend
remains and to direct the disposition of the cremated remains, that anypersona and l save harmless
ossessions
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 rem
as di ected, whether such claims or demands are, or are not, wholly groundless, ains
false ai fraudulent.
Witness
Signatur o Relat ve Legal Rep,
68. Main St , Hudson Falls , NY 12839 29 Elizabeth st. , Queensbury, NY
Address Address 12 804
Signed on this date
6/5 �..,