Barrett, Helene rl-o q+N OF QMBUrUEE kY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director� �{,�,���j
NamekurAC Tf Case # x3
Date of Cremation
Time Cremation Started �Q 'XE/ 't1y)
Time Cremation Completed `9-/ /C )0,,Ml
Type of Container '1fi��1 � Gl�'�T
Remarks : 7
s
i
i
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:
Helene Kelly Barrett Female
(Name) (Sex)
Indian River Nursing Home Granville,NY 1283
(Street) (City) (State) (Zip Code)
who died on 24th day of June 2001
at Indian River Nursing Home Madison Street Granville,NY 12832
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs.Jacklyn Barrett-Shutts 1200 Ridge Road, Queensbury,NY 12804
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowled e, the deceased has or (:ha:s::n;�,.
pacemaker in his or her body. (Circle Onel
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 reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent. '
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address)
(Si nature of Relative or Legal Rep. and Addre s)
Signed on this date: L /