Rock, Guyle , rrnq+N OF QUEEN
BUJ2 Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
/a� Funeral Director �` �,(,,� /6/x
Name C-1- A0 Case
Date of Cremation r� p2d�3
Time Cremation Started //t 5� " 141-AA c
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Time Cremation Comoleted
Type of Container }•�j/�'�� �/y � ��, � ��C/ C�/��/•��/
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:
Guyle Joseph Rock Male
(Name) (Sex)
9 Mechanic Street Hudson Falls, NY 128*3A
(Street) (City) (State) (Zip Code)
who died on 17 day of October , 2001
at
(Place) (Address
Name and address of nearest living relative or name of person authorizing cremations:
Amy Tucker 6 Charlotte Ct enc F�T31 c . 11TY_—
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Carleton Funeral Home Inc.
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 crematipn
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.
68 Main Street, Hudson Falls , NY
(Witness) (Address)
X
(Signature of Relative�oregal Rep. and Address)
Signed on this date: October 18 2001