Mitchell, Charlotte rrO gtiN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C ICOR - `�c7 4A
Name GHi�-Ri.- -TTE 141,c R-E �.L Case # S L'\ U
Date of Cremation Z— 1 r� - Q cc-/ /
Time Cremation Started Q , 3 o 'Ir -/L
Time Cremation Completed
Type of Containers
Remarks :
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TOWN OF QUEENSBURY � ' LI6
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:
Charlotte Ruth Mitchell Female
(Name) (Sex)
Pleasant Valley Nursing Fac Argyle,NY 12809
(Street) (City) (State) (Zip Code)
who died on 13th day of December 2002
at Pleasant Valley Nursing Fac Route 40 Argyle,NY 12809
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Bryan Fuller 12 Liberty Place, Hudson Falls,NY 12839
(Name) (Address)
Relationship to the deceased Cousin
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 such claims or demands are not wholly groundless, false or fraudulent.
68 Main Street P.O.Box 67, Hudson Falls,NY 12839
Man
g.ss) (Address)
(Si a of Relative or Legal Rep. and Address)
/ l
Signed on this date: 2 ( �3 l a