Jackson, Jean rl-O q+N OF QUEEN,5BUWY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � dA0 T/Y
Name //� Ti lc �/V Case '#
Date of Cremation "= /j ` acLl l
Time Cremation Started '416a I
Time Cremation Completed IMF
Type of Container ,t�/pVA7 XD A:5,7G195-29E 0 721i�` f�iY
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY oZ�S
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:
Jean- Elizabeth Jackson
(Name) (Sex)
Hallmark Nursing Centre Queensbury, NY 12804
(Street) (City) (State) (Zip Code)
who died on 9th day of May 2001
at Hallmark Nursing Centre Queensbury, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Anna Maranville Homestead Trlir Park Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Gar4etenFareraa lk)ff-- Ine
IMPORTANT: Das
I represent that to the best of my knowledge, the deceasedr has no
pacemaker in his or her body. (Circle One)
1 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 crest'lation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
Carleton Funeral Home Inc .
(Witness) (Address)
�'4 Queensbury, NY
(Signature of Relative or Legal Rep. and Address)
Signed on this date: - A, / C)