Ricketson, Jean rrO TVN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director L)IJ:4-g q�)
Name 6 Case# --L,
Date Of Cremation G Z
Time Cremation Started 1
Time Cremation Completed
am l
Type of Container
Remarks
TOWN OF,
QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Cremaori m 745-447.7(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:
Jean Ricketson Female
(NAME) (SEX)
12 Rosalie Avenue, Warrensburg, New York 12885
(STREET) (CITY) `I, (STATE) (ZIP CODE)
who died on the 14th day'of December 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:
Duane Ricketson -`.fin fit s 0 jr.�S fe,111life /Va Y /a X57
Relationship to deceased Son...
Name of Funeral Home Alexander Funeral Home, Inc. , Warrensburg, NY 12885
IMPORTANT
I represent that to the best of my knowledge, the deceased KKMhas no pacemaker inher
body. (CIRCLE ONE)
I certify that I have the full power and authorization to arrange for the cremation of the remains ana
to direct the disposition ofthe.cremeted rem t g,¢that.any;persppal possessions have either been
removed or may be destroyed;jand#agree tQ;.�4� tj�defend:acws;ve 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 or are not wholly groundless, false or fraudulent.
4
^_ __—,T hn S. Alexander, 3809 Main St, Warrensburg, NY 12885
(7r) D RyE S%9)
Ta;n Re k 30 X,e
(STGNA E OF R LATNE OR LEGAL REP. AND ADDRESS)
Signed on this date: 12/14/02