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Hewitt, Vivian TOq+N of QUEEM,s5BU y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEEINSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director c t _ / Q Name / Case # Date of Cremation Z- Jam) Time Cremation Started It Time Cremation Comoleted 1,6 f r Type cf Container e�,M Al G A-10�:� CZNP Remarks : hl) /All r 12!� r/a /� r z91 n�1 J 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: Vivian Mabel Hewitt Female (Name) (Sex) 41 Harrison Ave. Glens Falls,NY 12801 (Street) (City) (State) (Zip Code) who died on 24th day of July 2001 _ at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: i Deborah Thaxton 41 Harrison Ave., Glens Falls,NY 12*1�~ (Name) (Address) Relationship to the deceased Daughter cif 1. t Name of Funeral Home Carleton Funeral Home,Inc. IMPORTANT: I represent that to the best of my knowledge, the deceased has or y 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 Cr oration of the remains and to direct the disposition of the cremated remains, that,..4y 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 thernq;-„_: a by reason of or connected with the cremation of said remains as directed, whether such claims or demands are not wholly groundless, false or,fraud0opt. 68 Main Street P.O.Box 67, 'Hudsoti*lalgs STY 12839 (Witness) (Address) i (Signature of Relative or Legal Rep. and Address) Signed on this date: 21 �