Foley, Olga rrO%N OF QUEENs5BURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, -NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director�`���,/� '/1(
Name, (fir a � � Case # xt/, %"
Date of Cremation
Time Cremation Started /�6 pzcy �pjm
Time Cremation Completed &� �! ►
Type of Container
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:
nl as Gerttade Foley f e m a l e
(Name) (Sex)
240 Dixon Rd. Queensbury NY 12804
(Street) (City) (State) (Zip Code)
who died on 31 st day of August , 2001
at 240A Dixon Rd . , 0ueensbury, NY 12804
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Janice Foley, 240A Dixon Rd. , Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Gaa-leten Funea-al Heim Ine,
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or Kas n
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.
( �'a 68 Main Street, Hudson Falls , NY 12839
(Witness) (Address)
240A Dixon n r804
(Signature of Rel tive or Legal Rep. and�Address)
Signed on this date: 8/31/01