LeFebvre, Marjorie T07+N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Clk
Name ��6Lf— 14qeCase #
Date of Cremation
Time Cremation Started
Time Cremation Completed (.C- 3o
Type of Container 44 V4,
•I
Remarks :
IET
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dr,py
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:
Marjorie June LeFebvre Female
(Name) (Sex)
29 Hillview Dr. Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
who died on loth day of August 2004
at G1 ens Falls Hospi tat 100 Park Strept Hudson Fails, hiv 1 mq
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Robert M. LeFebvre 29 Hillview Dr. Hudson Falls NY 12839
(Name) (Address)
Relationship to the deceased Hudbbnd
Name of Funeral Home Ga, -Iete., z,, H„Q,e T
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.
68 Main st. Hudson Falls, NY 12839
(Witness) (Address)
(Signature of elative or Legal Rep. and Address)
Signed on this date: