DeVault, Emma OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director G S/�.,j�i1,1�, � i Q
Name 1�/VtAkA V (/ PJ/A01—+ Case # 'L[ f�
Date of Cremation /b L I-1 lyLf
Time Cremation Started
Time Cremation Completed
Type of Container f', iA-`�i� a .*,+x 6Y ,�, �� j`-�•-�
Remarks :
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:
Emma V. DeVault female
(Name) (Sex)
65 Elm St. Hudson Falls NY 12839
(Street) (City) (State) (Zip Code)
who died on the First day of October 2004
at Eden Park Nursing Home, Warren st, Glens Falls, NY 12801
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs. Joan Williams 65 Elm st-, uudson Falls, NY 128'iq
(Name) (Address)
Relationship to the deceased Niece
Name of Funeral Home Ga.-Ieten Fuxieral Heue 1
m.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (,hlasno
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.
V
itness) (Address)
t 65 Elm St, Hudson Falls, NY 12839
(Signature of Relative or Legal Rep. and Address)
Signed on this date: 10/1/04