Vernum, Patricia TORN of QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director 1—
Name 2nT y"\C' 1 A yf-(L'NV N Case# 5�
Date Of Cremation 1 - `Loc --,
Time Cremation Started 1 ";')._�;' 10 ,M
Time Cremation Completed 3 `3 D V '",
Type of Container �'z 1
Y P G 1A c7�a�a-fl-r� �N�� (p,
Remarks
Move- d —
z.
TOWN OF,QUEENSBURY r
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518),Crematorim 745-447.7 (if no answer)
Cemetery 745=44.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View-Crematorium, in accordance with and sublecc
to its Rules and Regulations to cremate the remains of:
Patricia R. Vernum Female
(NAME) (SEX)
110 Main St. , Hudson Falls, New York 12839
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 13th day'of Dec. 2002
at Glens Falls Hospital, Glens Falls, New York 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Ma.rge Parker, Schroon River Rd. , ,Warrensburg, NY 12885
Relationship to deceased Step—daughter
Name of Funeral Home Alexander FH,Inc. , Warrensburg, NY 12885
IMPORTANT
I represent that to the best of my knowledge, the deceased Chas 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 anc
to direct the disposition of the cremated remains, that any,personal possessions have either been
removed or may be destroyed;'and=:agree to,ptptect;defend and5ave harmless Pine View
Crematorium from any and all claims and demands for loss or damages which may be made
ag i them y reason of or connected with the cremation of said remains as directed, whether
ch claims r demands are or are not wholly groundless, false or fraudulent.
i Warrensburg, NY
(WITNESS) (ADDRESS)
j,z PCt&k�[ Same as above
(SIGNARTUIRE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 12-14-02