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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4-477
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PINE VIEW CEMETERY AND CREMATORIUM
RECEIPT FOR BODY
1. NAME OF DECEASED AS IT APPEARS ON THE BURIAL-TRANSIT PERMIT
F � r
2. DATE THE BODY WAS DELIVERED
N 1-1, 1003
3. AND LICEUSE WJMBER OF FUNERAL DIRECTOR OR UNDERTAKER
4. FUNERAL FIRM REPRESENTED BY FUNERAL DIRECTOR OR UNDERTAKER
5. (NAME OF PER N IN CHARGE OF CEMETERY
6. SIGNATURE OF FUNERAL DIRECTOR OR UNDERTAKER
7. SIGNATURE OF ERSON IN CHARGE OF CEMETERY
8. NAME OF CEMETERY EMPLOYEE WHO RECEIVED BODY
9. SIGNATURE OF CEMETERY EMPLOYEE WHO RECEIVED BODY
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:
Frederick Fuss male
(Name) (Sex)
12 Steohen Drive Hudson Falls , NY 12839
(Street) (City) (State) (Zip Code)
who died on 15th day of November 2003
at 12 Stephen Drive, Town of Kingsbury, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Aileen V. Fuss 12 Stephen Drive. , Hudson Falls, NY 12839
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home Carleton Panera, Hwe ine.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has 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
Carleton Funeral Home, Inc.
(Witness) (Address)
_1` �r/' - / u 12 Stephen Dr. , Hudson Falls, NY 12839
-1i-(-Signature of Relative or Legal Rep. and Address)
Signed on this date: