Stevens, Chester TO"WN OF QUEENB` jKy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4.476 (518) 745.4-477
Funeral Director Ave,14ct."fl-er-
%a7e evert Casey
=a ; e Of Cremation
Cremation Started
T.e Cremation Completed
pe of Container
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TOWN OF DUEENSBURY
PINE VIEW CEMETERY
a
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 :
Chester S. Stevens Male
(Name) (Sex)
1819 E. Schroon River Rd. , Warrensburg, NY 12885
(Street ) (City) (State) ( Zip Code )
w h o died on 25 th —day of March pcx 2004
at Adirondack Tri-County NH, North Creek, NY
(Place) (Address)
Name and address of nearest living relative or name of Pe,-son
authorizing cremation :
i
I Patricia A. Hensler Same as above
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander-Baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge, the deceased h*Mx(Xxx
j 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 there b`-
reason of . connected with the cremation of said remains as
directe,d;�� wh her such claims or demands are or are not wholly
groundless, alse or fraudulent .
t Warrensburg, NY
(Wi ess > (Address )
rG Same as above
(Sig ture of Relative or Legal Rep. and Address)
Signed on this date :
I