Pitcher, Elgin rro OF QUEEM
,s5B U9�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, INEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ��. t �� C2, Case #
Date of Cremation �--
Time Cremation Started ,z 0
Time Cremation Completed „� 1✓` " 1
Type of Container cAc1-2-0 2 C411451
Remarks :
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
Elain L. Pitcher male
(Name) (Sex)
13 Preston St . Hudson Falls Ny 12839
(Street) (City) (State) (Zip Code)
who died on q1/8/n2 day of
at Glens Falls Hospital , Glens Falls, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
—_John Earl . PO Box 125 , Kattskill Bay, NY 12844
(Name) (Address)
Relationship to the deceased nephew
Name of Funeral Home G«Pcea Funeral Hare T
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no
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,
whe her such claims or demands are not wholly groundless, false or fraudulent.
it S) . n t . Hudson Falls NY 12839
J (Address)
x 125 Kattskill Bav, NY 12844
(Signature of Relative or L al Rep. and Address)
Si ed on this date: 9/9/02