Balch, Paulinew TOWN OF QUEENs5BU2 �
PINE VIEW CEMETERY AINI) CREMATORIUM
QUAKER ROAD. QUEENSBURY, :v'EW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral9 Director C w )" l
Name ��'}(� }. � E Lj, Case # 2l �
Date of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container C° K6.0
Remarks : �"iR5"fi � �'ts �'� �t
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TOWN OF QUEENSBURY • ��? j
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:
Pauline W.Balch Female
(Name) (Sex)
Hallmark Nursing Centre Queensbury,NY 12804
(Street) (City) (State) (Zip Code)
who died on 5th day of November 2002
at Hallmark Nursing Centre Granville,NY 12832
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Grace Fish 40 Harrison Avenue, Glens Falls,NY 12801
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Carleton Funeral Home,Inc.
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,
whether s ch claims or demands are not wholly groundless, false or fraudulent.
( � 68 Main Street P.O.Box 67, Hudson Falls,NY 12839
Witness) (Address)
') :7b 40 Harrison Ave, Glens Falls, NY 12801
ignature of Relative or Legal Rep. and Address)
Signed on this date: 0-7 Q Z