Diaz, Carmen �o OF QUEEVBU_f�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorI�`� �
Name_ Gift12M Chi `� i TL_ Case # '-1
Date of Cremation c— J 3 = -ze�, y
Time Cremation Started
Time Cremation Completed � G
Type of Container A-14 36 14,11
Remarks :
9 ���
TOWN OF QUEENSBURY ��
PINE VIEW CEMETERY
8
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-44.76
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
CARMEN HERNANDEZ DIAZ MALE
(NAME) t t (SEX)
SAN CRISTOBAL DELAS CASAS , CHIAPAS , MEXICO
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 5TH dayof SEPTEMBER 20_flLL_
atHADLOCK POND , FORT ANN , NEW YORK 12927
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
JUAN JIMENEZ RUIZ , 152 NORTH WILLIAMS ST. , WHTTFHAII . NY_ 12887
Relationship to deceased F R I E N D
Name of Funeral Home MASON FIINFRAI HnMF . FOR,T Awl , NY. 12227
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
.6—ematorium 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 or are not wholly groundless,false or fraudulent.
PA . BOX 277 , FnRT ANN , NY _ 1Z827
(WITNESS) (ADDRESS)
x ,� �— , SAME AS AROVF
(SIGNATURE OrITELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: S E PT . 10 , 2004