Martin, Edward Sr. . TOWN OF QUEEM5B U9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD. QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorGAR, -0/14
Name ,D 12 Rr/`!l S . Case #
Date of Cremation
Time Cremation Started
1
Time Cremation Comoleted I
Type of Container ���/C��j�
Remarks :
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TOWN OF QUEENSBURY t -
PINE VIEW CEMETERY
& O�
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:
Edward Vincent Martin Sr. Male
14(Name) (Sex)
11i95 Martindale Ave. Kingsbury,NY 12839
(Street) (City) (State) (Zip Code)
who died on 2th day of May 2002
at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs.Pearl R Martin .1B95 Martindale Ave. Hudson Falls NY 12839
(Name) (Address)
Relationship to the deceased Wife
Name of Funeral Home Carleton Funeral Home Inc.
IMPORTANT: --�
I represent that to the best of my knowledge, the deceased has or Lhasno
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cremation
of the remains and to direct 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 View Crematorium from any and all
claims and demands for loss or damages which may be made against them
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.
0� j �"C ,
"/L 68 Main Street P.O.Box 67, Hudson Falls,NY 12839
(Witness) (Address)
149 Martindale Ave. , Hudson Falls , NY
(Signature of Relative or Legal Rep. and Address)
Signed on this date: 5/3/02