Phelps, Clarence rn q+N OF QUEEM,s5BUy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :r'EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Namec/A C05 f—#-9 L Pb:LCase
Date of Cremation Az — ZI
Time Cremation Started 4hyo 6l L'1 /
Time Cremation Completed � .$�
Type of Container
Remarks :
r 6 /M f
17
-3a 19/4 r
Aec 15 01 10: 58a Brougham Estates II 913-299-9062 P. 1
FROM M.B.KILMER FUNERAL HOME FAX NO, Dec. 15 2001 12:37PM P1
TOWN 07 CUEENSBLRY
PIN€VIEW CEMETERY
CREMATORIUM
Quaker Rose. OL&O spury, Now York 12804
Phone r5181 Crematorium 745.4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pure View Crantatortum, in accordance Willi and subject
to its Rules and Regulations to cremate the remains of:
GIarence H. .Phelps Mate
IS(NAME) (SEX)
K'Cooper St. Fort Edward NY 12828
(STREET) ,`CITY) (STATE) (Rf CODE)
who died on. l 5 day of December 2D 01
at Albanv Medical Center, Albarry, NY
(PLACE) (ADDRESS) r
Name 81td address of nearest living relativa or name of persoft•Authortzing cremation:
Karen Bertsch, 1720 North 73rd Terrace Or Kansas City, KA
Relationship to deceased 11AlightEr
Name of Funerat Home 14. g. Kilmer Funeral Home
IMPORTANT
I represent that ltr the test of my knowiscleA the deceased boor hss nc pacemaker in his or her
body, (CIRCLE ONE)
I caftiy tttzt t hfte the full power and authorization-to arrang*for the crearauon of the remains and
to dired the disposition of the cremated remains,that any perional possessions have either been
removers or may tw destroyed.and agree to prated,defend and*We harmless Pine View
Crematorium from any and all claims and demands for lass or damages which may be made
against them by reason of or corrected with the cremation.of said remains as directed,whether
such claims or demands are or are not wholly groundless,false or fraudulent.
(tNl NESS) (AE)DREW
(SIGNATURE R A .AND ADDRESS
f / LEG L )
Signed on this data t o)- f 1S/O 1