Mingo, Kenneth Sr. �o QUEEVBU-Iky
PINE VIES' :: IETERY AND CREMATORIUM
QUAKER R,): QUEENSBURY, NEW YORK 12804
(51 S' ' --4476 (518) 745-4477
IF al Director Gwiz r-4—C)
NameL��� ��r� �, - M 1 �� ase # 3 `�
Date of Cremation ] - Q ''!�"��i� Ll
Time Cremation Starte .
Time Cremation Comple : �- �
Type of Container -j��y� � , C( � �� 1�/Vl
Remarks :
TOWN OF QUi ENSBURY
PINE VIEW CF; 'ETERY '
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:
Kenneth Louis Mingo—Sr. Male
(Name) 311 (Sex)
Lot 21, Stone Church Rd Ballston Spa,NY 12020
(Street) (City) (State) (Zip Code)
who died on ihth day of August 2004
at Kingston Hosptial ,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
3 �
Jacqu6lir i n--, Ruff , Lot 21, Stone Church Rd Ballston Spa,NY
(Name) (Address)
Relationship to the deceased Jacqueline Ruff , = daughter
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has C�D
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 uch claims or demands are not wholly groundless, false or fraudulent.
-- � /- W 68 Main Street, Hudson Falls, NY 12839
Witness) (Address)
r Lot 21 , 315 Stone Church Rd Ballston Spa
( ;gnature of Re ative or eg I ep. and Address) NY 12020
Signed on this date: I� U4