Lemery, Evelyn TOWN OF QUEENSBURY
Pine Vteto Cemetery and Crenlntnrllllll
21 Qunker Rond. Queenshury, NY. 12804.5902
(518) 74 5.44 76 (518) 745.4477
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Funeral Director: (,c+r tfu,.
Name of Deceased: Ewe L # -r\
Case Number: ( �
Date of Cremation:
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Time Cremation Started:
Time Cremation Completed: Liu
Type of Container: ��/d �pa It V✓/ w10A
Remarks:
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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:
Evelyn Marie Lemery female
(Name) (Sex)
53 Burgoyne Ave Fort Edward NY 12828
(Street) (City) (State) (Zip Code)
who died on the 3rd day of May 2005
at 53 Burgooyne Ave, Fort Edward, NY 12828
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Patri r-i a 7arnaWf 7R Thnrnwnnd Dr , Pnrt Fdward, Ny :1 9828
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Ga�-Iet9n Fun al Hwine
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or Chano
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.
T
(Wi ness (Address) '
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(Signature of R tive or Legal Rep. and Address)
Signed on this date: