Loveland, Karen rro WN OF QUEENB UJ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :,EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director fkf, 6- /31V
Name kYl ,�/� /,�7�,�i�/9/V Case #
Date of Cremation o oZGY�!
Time Cremation Started
Time Cremation Completed / J / 4.:!!�')9rM '
Type of Container �f-/ i9$(C,lj::17;j ' /-7-
Remarks :
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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:
Karen (LaPlanche) Loveland Female
(Name) (Sex)
Maple St.YPPt, nlPns Fa11S, NY 12801
(Street) (City) (State) (Zip Code)
who died on 14 th day of August
at Glens Falls Hospital, Park Street, Glens Falls, NY
(Place) (Address)
3
Name and address of nearest living relative or name of person authorizing cremations:
Larry LaPlanche, 4 Roger Street, Apt. P.O. Box 91, Fort Edward, NY 19828
(Name) (Address)
Relationship to the deceased brother
Name of Funeral Home G&-leten Funeral Fief e ine.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
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.
-'--� -& 0 44A41--1
(Witness) (Address)
ignature of Relative or Legal Rep. and Address)
Signed on this date: