Fuller, Ronald rrOgtiN OF QUEENs5BU�ZY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, ti"EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorG',� ,���� /�
Name-X- I-y Case #
,
Date of Cremation !�'"--e
Time Cremation Started ! 4 / �jM
Time Cremation Comoleted / Q �//`(� 1
Type of Container/1 /9ycz-6 /7
Remarks :
Z/-ir
' TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road Queensbur
Phone (518) Crem y, New York 12804
atorium 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:
Ronald Leroy Fuller Male
(Name) (Sex)
34 Feeder Street Hudson Falls,NY 12839
(Street) (City) (State) (Zip Code)
who died on 14th day of August 2001
at 34 Feeder Street -
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Janet Fuller 34 Feeder Street, Hudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Fife
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent tha o the best of my knowledge, the deceased has-
pacemaker 6r '1'(as no
i is or-Jw body. (Circle One _ � 11A
iViry,}^;
I certify that I have the full power and authorization to arrange for the::�pIrmation
of the remains and to direct the disposition of the cremated remains, that any
personal possessions have either been removed or may be destroyedr. d 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'the- m
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)
s r- tom!"P-f0,-J �,Efcy r7
(Signature of Relative or Legal Rep. and Address)
Signed on this date: 14dG us- /7 , 900/