Phelps, James r'-o OF QUEEN
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEEINSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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Time Cremation Started 6ct
Time Cremation Comoleted /
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09/17/2001 08:18 6955670 FLYNN BROS PAGE 02
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crematorium 745-4477 (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:
James Phelps Male
(NAME) (SEX)
43 Mahaffey Road Greenwich, NY 12834
(STREET) (CITY) (STATE) (ZIP CODE)
15th September 20 01
who died on _ day of .—^
at McClellan Health Systems Hospital Cambridge, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Karen Phelps - 1755 Huntersbrook Yorktown Heights, NY 10598
Relationship to deceased Daughter
Name of Funeral Home Flynn Bros. , Inc. - Greenwich, NY 12834
IMPORTANT
I represent that to the best of my knowledge, the deceased has r has 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 are not wholly groundless, false or fraudulent.
( NESS) DDRESS)
a21�l 1755 Huntersbrook, Yorktown Heights, NY 10598
(SIGNATURE OF R TIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: Sept. 17, 2001