Mace, James TOcWN OF QUEENBUWy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, N TW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 7C,9/�,� —�,�p�
Name P4 C-5 x Case # 4 V
Date of Cremation 4
Time Cremation Started / ecs*f s 1
Time Cremation Completed 6z44
t
oon' i^M c
Type of Container 6/g/P�7�//�1
Remarks : � i -
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13f2001 14:39 518-548-7402 SUNMOUNT DDSO HAMCO PAGE 04
s env• a1:a1 PM FORTUNE-IKEOUGM 1 518 091 Z414
P.8°
e TOWN OF QUEENSSURY
PINS VIEW CEMIETERY ��r��'
• 099MATORIUM
Quaker Road,Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 74544.76
AUTWORmAmON TO CREMATE
The undersigned requests and authorizes Pine Yew Cremstorlum, in accordance with and suoieet
to its Rules and Regulations to Cremate the remains at
James Mace Male
(NAM ) (SEX)
48 Underwood Road, Tupper Lake, NY 12986
(STREET) (crTY) ( ) ZZIP7351T
who died on 11 day of December -20_j2L
a�Adirondack Medical Center at Saranac Lake_ jjv
(PLACE) (ADDRESS)
Name and address of nearsat living relative or name of person authorizing cremation:
Diane Cardiff, 48 Underwood Rd. , Tupper Lake, NY 12986
ReMonshiptodeceased caregiver-friend
Name of Funeral Home Fortune-Keough-Renne11 Funeral Nome Inc.,
IWORTANT
1 represent that to the best of my knowledge,the deceased DU patentaker pt nis or her
body, (CIRCLE ONE)
1 certify that I have the full power and authorization to arrange for the cremation of the remains and
to dkwt 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 Vlew
Cremaicrium from any and all claims and demands for loss or damages which may be made
against them by reason of or oonnected with the oremaWn of sold remains as directed,whether
such cI ma or demands=lotwholly groundless,false or fraudulent
iWITNESS) DREss
� �
(SIGNATURE OF RELATIVE OR LAGAI.REP.A O ADDRESS)
Signed on this date: t Z/iil o l