Kingsley, Flora ry-o WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C1, �z 1, F
Name U ��� � � r� �` F Case # � 3 � .
Date of Cremation. IC' s & 7C'c'
Time Cremation Started e'30 5 A- 11
Time Cremation Completed
Type of Container
Remarks :
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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:
Flora Mae (Morris) Kingsley Female
(Name) (Sex)
1165 Farley Road Fort Ann, NY
(Street) (City) (State) (Zip Code)
who died on day of
October
at Glens Falls Hospital Glens Falls,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Frank W. Kingsley 1165 Farley Road Hudson Falls, NY
(Name) (Address)
Relationship to the deceased Husband
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or hasDno
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,
wheth ch claims or demands are not wholly groundless, false or fraudulent.
641� L::::21 68 Main Street, Hudson Falls, NY 12839
/ (Witness) (Address)
(Sighature of Relative or Legal Rep. and Add ess)
Signed on this date: