Vaughn, Charles ""RN OF QUEEMB URY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -,EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director (f�V,05
NameC7�l �E!�i ,�g�rr /�/�� Case #
Date of Cremation
Time Cremation Started oe/ /9 / M j
Time Cremation Comoleted �1'400 / m ,
Type of Container ry- f? C-ZQ T ��1�,�" T �� �;��► -®,�-rye-
Remarks : klFc7lfD
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM .3
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:
Charles Ernest Vaughn Male
(Name) (Sex)
G.Roswell Earl Towers Apartment#5F Hudson Falls,NY 12839
(Street) (City) (State) (Zip Code)
who died on 5th day of June 2001
at G.Roswell Earl Towers Apartme
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Paul M.Vaughn 40 LaCrosse Street, Hudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or-, has n.o
pacemaker in his or her body. (Circle One)
L,
I certify that I have the full power and authorization to arrange for the creifla`tt&
of the remains and to direct the disposition of the cremated remains,.that an
personal possessions have either been removed or may be destroyed;` �
,ancf' X
to protect, defend and save harmless Pine View Crematorium from any and It
claims and demands for loss or damages which may be made agai.nst.,tha
by reason of or connected with the cremation of said remains as..directp,dR A{A ,J
whether such claims or demands are not wholly groundless, false7.pr fr"" "
J� 68 Main Street P.O.Box 67, Hudson'Fa1[1s,`NY'12839
( QnessUo'��
(Address)
40 LaCrosse St. Hudson Falls NY 128
(Signatu elative or Legal Rep. and Address)
Signed on this date: