Davis,Berenice TOWN OF QUEEN5BUP,,_Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name z s Case #
Date of Cremation to H
Time Cremation Started && f�
Time Cremation Completed o clo A M
Type of Container Cc wG L . e l% �•, oA crik
Remarks :
C'_G,i d`lu, A 11
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:
SPrenice F navis fPma1P
(Name) (Sex)
50 Burgoyne Ave. Fort Edward NY 12828
(Street) (City) (State) (Zip Code)
who died on the 25th day of October 2004
at Glens Falls Hospital, Glens Falls, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Stephen G. Davis, 50 rt RdwArd, NY NY 1282@
(Name) ( dress)
Relationship to the deceased son
Name of Funeral Home Ga� sctenruneral Hem—Inc
IMPORTANT:
I represent that to the best of my knowledge, the deceased has o 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 re son 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 12899
(Witness) (Address)
�12� 50 Burgoyne Ave, Fort Edward, NY •12828
(Signature of Relative or Legal Rep. and Address)
Signed on this date: