Tennyson, Charles rro`KN OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director �,r-� 1� 1�-
Name F4 T'10t+ I\. Case# X 3
Date Of Cremation G
Time Cremation Started
Time Cremation Completed
Type of Container nKlfwooD 147 1, 1y- 1 D H�
Remarks
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TOWN Oi= & j.WRY
PINE Vi ;iCEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematq :_74577r7.(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:
Charles H. Tennyson, Jr. Male
(NAME) : t (SEX)
100 Cornelia Street, Plattsburgh, New York 12901
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 30th day'of December 2002
at His Home on Cornelia St Plattsburgh, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mr. Charles H. Tennyson, Sr. , 187 Stock Farm Rd, Chestertown, NY 12817
Relationship to deceased Father
Name of Funeral Home Alexander Funeral Home, Inc. , Warrensburg, NY 12885
IMPORTANT
I represent that to the best of my knowledge, the deceased jgffKhas no pacemaker in his KKKKK
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.cfemqited remgo,�that-any;per sR glt possessions have either been
removed or may be destroyed'andiagree torptOtBct,<defendadc aYs 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 clAs or demands are or are not wholly groundless, false or fraudulent.
..___John...S. Alexander, 3809 Main St, Warrensburg, NY 12885
(WITNESS) (ADDRESS)
�,VCharles H. Tenn son Sr 187 Stock Farm Rd Chestertown,
(SIG NATURE OF R LATR LEGAL REP. AND ADDRESS) New York 12817
Signed on this date: 12/31/02