Salmon, Diane rrDRN OF QUEEMB2 99 Y
PINE VIEW CEMETERY AND CREMATORIi:M
QUAKER ROAD, QUEENSBURY, Nv'EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C, 19 10570 14
Name /f fi/V.-C- S&A4&zV Case # /7' 571
Date or Cremation
Time Cremation Started IV)
Time Cremation Comoleted �
Type of Containergg&C.,167y G �7-
Remarks : C//,w4/ Q/P,�
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
9�
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: _
Diane Hilda Salmon Female
(Name) (Sex)
169 Broadway Schuylerville,NY 12871
(Street) (City) (State) (Zip Code)
who died on 16th day of September 2001
at St.Peter's Hospital 315 S.Manning Blvd.Albany,NY 12208
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Thomas Salmon 920 Delano Court, Kissimmee,FL 34758
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home Carleton Funeral Home,Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or,C-,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 arty
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,
whethe such claims or demands are not wholly groundless, false or fra idulent.
68 Main Street P.O.Box 67, Hudson Falls,INY 12839
(Witness) (Address)
Signature Relative or Legal Rep. and Address)
Signed on this date:
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