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Corlew, Edward Sr. 7n74N OF QUEEVBU9� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director L A\2,k-F,1::to(- , Name- �' ;A �Q J-�-- Case# Date Of Cremation Time Cremation Started s /VL Time Cremation Completed �, � �( n Type of Container C u-v-,, CA'rKc-t' /VI ,tq Remarks TOWN OF QUEENSBURY �! 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: Edward Foster Corlew, Sr. (Name) (Sex) 665 County Route 41 Kingsbury,NY 12839 (Street) (City) (State) (Zip Code) who died on 25th day of AFebr:wiry 2003 at Glens Falls Hospital 100 Park Street Glens Falls,NY 12801 (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: Jeanette Corlew 665 County Route 41, Hudson Falls,NY 12839 (Name) (Address) Relationship to the deceased \,/,i ; (e Name of Funeral Home Carleton Funeral Home,Inc. IMPORTANT: I represent that to the best of my knowledge, the deceased has or as 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. V �f��—� �—�, 68 Main Street P.O.Box 67, Hudson Falls,NY 12839 (Witness (Address) (Signature of Relative or Legal Rep. and Address) Signed on this date: a 5— a 0 ©3