Welchko, Alice � � OF QUEEN5�� B U9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,Odfirw;c
Name ��(.,% G,� l�}, �C17 Case # /30
Date of Cremation 3 19 ak a
Time Cremation Started 9i�,�'/9rm i
Time Cremation Completed
Type of Container_(' /�,D�(7Vi7�� �/yDi Gf'�S�O�� 'T&K7 0/9'
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03/16/2002 08:39 8028776792 LAURIE GUTOWSKI PAGE 01
V rfIL Vy.. uunrC[ rulutnAL HUMt; 802265BOB5; Mar-16-02 8:33AM; .P3 e. i.n 9 /1
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TOWN OF OUEENSBURY
F PINE VIEW CEMETERY
CREMATORIUM l 2
Quaker Road, Queensbury, New York 12804 `/ J
Phone(518)Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
AUTHORIZATION TO CREMATE
s
Th undersigned requests and authorizes Pine View Crematorium, in accordance with and subject .
to is Rules and Regulations to cremate the remains ot:
Mrs. Alice M. Mlelchko t rcmalc
t (NAME) (SEX)
9 Haywood Avonue, Rutland, Vermont; 05701
(STREET) (CITY) (STATE) (ZIP CODE)
k
i
whi died on 7 5th day of t1droh 20 02
a k Ht. Vl.ew Center, Genesis Eldercare Nursing Ilome,Rutland Vermont
(PLACE) (ADDRESS) .
Nafne and address of nearest living relative or name of person authorizing cremation:
.t
Laurie Gutowski t' 0 Bu_x_ 122,E N ortb Farr;s1 gth,
a
4
R4ationship to deceased Gijard.ia.n
s.
1
Name of Funeral Home ourfee Funeral Home, Fair Haven, Vermont 05743
1,40RTANT
I r present that to the best of my knowledge, the deceased ftm or no pacemaker in his or her
body. (CIRCLE ONE)
I c tirtify that I have the full power and authorization to arrange for the cremation of the remains and
to firect the disposition of the cremated remains, that any personal possessions have either been
re oved or may be destroyed, and agree to protect, defend and save harmless Pine View
Cr matorium from any and all claims and demands for loss or damages which may be made
ai inst them by reason of or connected with the cremation of said remains as directed,whether
s h claims or demands are or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
��jjx D�' PI,(,b lI C �',l u.GUZ�.t,A�l•%-
Xx �` -
(S(GNATUR OF RELATIVE OR LEGAL REP.AND ADDRESS)
Sibned on this date: March 16,2002
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