Mumblo, Barbara TOq+N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C i'jQkj- fiQ i 1
Name )6h)J31 $ (Pk A fl)OMFJh{) Case # �7?
Date of Cremation fq - -2 )6 '4
Time Cremation Started D _ 1-1-5 14
Time Cremation Completed
Type of Container G i4t �gti?E� f i6A rr PrA,/
Remarks :
�1r2�4 12 1 c V-si% /40 �1 -41
�' 5 w��
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:
Barbara Ann Mumblo female
(Nam6) (Sex)
3511 State Route 196 Fort Ann NY 12827
(Street) (City) (State) (Zip Code)
who died on 6th day of June 2004
at Glens Falls Hospital , 100 Park St , Glens Falls, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Robert F . Mumblo 1 Elizabeth St. , Hudson Falls, NY 12828
(Name) (Address)
Relationship to the deceased son
Name of Funeral Home —Gaar=atei Funeral
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or hDasno
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,
whet er such claims or demands are not wholly groundless, false or fraudulent.
68 Main St. , Hudson Falls, NY 12839
(Witness) (Address)
1 Elizabeth St Hudson Falls NY 12839
(Signature of Relative or Legal Rep. and Address)
Signed on this date: 01 6/7/04
i