Foster, Jacob a
'rO7+N OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director � 4;Ir,,r%-f FH
Name �CICc,6 FL,�, ,eC Case # s;Jll
Date of Cremation
Time Cremation Started 0 Pfl
Time Cremation Completed b
Type of Container C(A4-(J 0cor E f , ��Cj (4u
Remarks :
►�,g,n 2 : a � PM . mum-c.Q ` 5°
11,'26/2004 10.48 FAX 860767V60 MARITIME TRADING Z ool
NOV-26-2eO4 1 0 7 1 1 AM rUCFIAFZME.FUNERAL• HOME S02 468 2226 P. 02
TOWN OF Q6691SISBURY
PINE Vir6YV CEMUERY
CREMATORIUM
Quaker Road,Qtteensbury, New York 12504
Phone(515)Cr9matorlum T45.4477(if no answer'r
Cemetery 7454475
AUTHORZATION TO CREMATE
The understgned reque9ft and autharizea Pine VOW Crernatorlum,in accardam with and 601e0-t
to ft RUtea and RegU atkMt to cremaaa the remains of;
Jacob Foster Ma le. SB
( a) (sex)
30 snook =ad , Danbu VT 0573-9
(STRE77 (CM1 (SPATE) (EP CCD
11)who died an day of Novemb"r Oa
Rut3arid oat Center 99 alien Atreet Rutlb V 0 1
{owDRESS
Name rand addimas of neared living relative or name of person authorizing cremation:
Alex Foster 308 8rocic Rd Danby vT 05739
R*%Uonahip to deceased Father
Name of Funwal HPme Ducharme Funeral Home Tno.
fiVlP RTANT
i rlepwmt plat to the hest of my knowledge,the deceased W or has glo paoemdwr In his or her
body. (CtRCLS ONE}
!awify that 1 have the fun power and authorization to arrange for On+cremation of the remains and
to diced the disposition of the cremated remains,that arty persmW possessbns have eUm been
or may be destroyed+and Wve to pmtoct,defond and save l�simleas Ptne Yfew
� iney be made
ltram bbre�n of ando r�wthe crernaUoa t saidw4s for loss or�renwi is axis did,whetor
s ad imtr or demands am or we not wholly groundless,false or fraudulent.
$$) (ADWESS)
i
E OF RE LAI iNPEOR LEGAL REP.AND ADDRESS)
)(Signed on this date: