Ehman, Infant Y
(7 OF QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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Date Of Cremation �� — � — `Z 00 j
T =�G Cremation Started l0
Time Cremation Completed_
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Remarks
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CtfWN OF QUEENSBURY
PINE V GVd CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crematorium 745-4477 (if no answer)
Cemetery 745-44.76
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:
Infant Ehman Female
(NAME) (SEX)
149 Montgiven Ave Fair Haven, Vt 05743
(STREET) (CITY) (STATE) (ZIP CODE)
2 October 24 03
who died on day of
Rutland Regional Medical Center, Rutland, VT 05701
at (PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Heather Ehman
Relationship to deceased Mother
Ducharme Funeral Home Inc.
Name of Funeral Home
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 or are not wholly groundless,false or fraudulent.
(WITNESS) (ADDRESS)
lv 0
(SIGNATURE O ELATIVE OR LEGAL REP.AND ADDRESS
Signed on this date: `U