Baker, Elmer rro`wN OF QUEEN5BU.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �/9 *?/14�Tp /q
Name , i /� � /� Case n GQ
Date of Cremation
Time Cremation Started
Time Cremation Completed/ t t<nc
Type of Container
Remarks : i�•�
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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:
Elmer R. Baker Male
(Name) (Sex)
Mary McClellan SNF Cambridge, NY 12816
(Street) (City) (State) (Zip Code)
who died on 20th day of November, 2001
at Mary McClellan SNF, Cambridge, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Delbert Ellsworth 29 Yole Dr. , Hudson Falls, NY 12839 -
(Name) (Address)
Relationship to the deceased caretaker
Name of Funeral Home
Carleton Funeral Home, Inc
IMPORTANT:
1 represent that to the best of my knowledge, the deceased ha.s� pr:.,' ,has no
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange fiar ticre.mation
of the remains and to direct the disposition of the cremated remains;.thpt q ,y
personal possessions have either been removed or may be destroyed, and agree
to protect, defend and save harmless Pine View Crematorium from :any a0dr:lh"
claims and demands for loss or damages which may be made against=theme:,�,•
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.
Carleton Funeral Home Inc.
(Witness) --� (Address)
29 Yole Dr. , Hudson Falls . NY
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Nov. 21 , 2001