Hayes, Elsie "WN OF QUEEMs5BU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, :NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �j�/'��
.,
Name �9-4s��,� ,� Case # mod`
Date of Cremation
Time Cremation Started Z 4d 2
Time Cremation Completed / l ' 1elYb
Type of Container L CAKov=-- �,,e691
Remarks :
Acq, °,5�� J°/m
Z p, AA
t3Y j"o/All
02/19/2002 11:00 5196422322 RCBERT M KING rH � PACE 02
...---—
TPINS 01W C M SPRY
41
CRE1utA'CCRIU
M
Cuaksr Road,Gueeumsbv 4A�(tPrno answer)
Phone(518)CrsCgametery 7454476
AUTHORIZATION TO CREMATE
The undersigned requests and authoriM Pins Crematorium, in accordance with and eubJect
to Its Rula3 and Regulations to cremate the remains
ot
E l s i e EX)
(NAME)
t,6 N x c k e 1 s St . Rutland VT 0$701(STATE), (xIP CODE)
(STREW (CITY)
20JU—
who died on t n e 19 h day of F — �—
at on ®(ADDRESS)
Name and address of nearest living relative or name of person aulhortzing cremation:
' 6
LorrRias Carl nxt-a—
Relationship to deceased
Name of Funeral Home gobart r+ • K a s r a i H
IMPORTANT o'�Pacemaker in his or her
i ripresent that to the beat of my knowledge, the decelsasd
body. (CIRCI.9 ONE)
I certify that I have the lull power and author4zatian to arrange forlthe cremation of the remains and
to dimct the disposition of the cremated remains,that any POrsOnPI possessions have either been
removed or may be destroyed,and agree to protect,defend and We harmless pine View
Crematorium from any and an ctahs and demands far loss or d .ages which may bs'made
against them by reason of or.connectsd with rocrem onl Of alsea r remaifraudns
as directed,Whether
such ciairns or demands are or are not wholly g
t.
TNESS)
(SIGNATURE OF RELATIVE O EGAL EP. AND AO ESS)
Signed on this date. / y