Wheeler, Victoria TO rMN OF" QUEE9� 5B U r
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
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TOWN OF OUEENSBURY
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:
Victoria Ann Wheeler female
(Name) (Sex)
42 River St . , Hudson Falls, NY 12839
Street
(City) (State) (Zip Code)
who died on 24th day of January, 2004
at Glens Falls Hospital , Glens Falls , NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Lawrence Wheeler 42 River St. , Hudson Falls , NY 12839
(Name) (Address)
Relationship to the deceased husband
Name of Funeral Home Carleton Funeral Home, inc .
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.
Carleton Funeral Home, inc.
(Witness) (Address)
42 River Street
Hudson Falls, NY 12839
(Signature of Relative or Legal Rep. and Address)
Signed on this date: Jan. 25 , 2004