Warren, Elizabeth ToT�N of QUEEM,
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.4477
Funeral Director f VA ,�
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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:
Eli_Zaheth J. Warren female
(Name) (Sex)
Wesley Health Care, Saratoga Springs , NY 12866
(Street) (City) (State) (Zip Code)
who died on the 4th day of January 2005
at_ Wesley Hea] h Care , Saratoga Springs, NY 12866
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Daniel Warren, 38 Hills Rd , Ballston Lake, NY 12019
(Name) (Address)
Relationship to the deceased son
Name of Funeral Home n.,,.,ete , ueffe T
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as D
pacemaker in his or her body. (Circle One)
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
clain)s 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 su claims or demands are not wholly groundless, false or fraudulent.
Kdl
68 Main St, Hudson; Falls, NY 12839
ss) (Address)
38 Hills Rd, Ballston Spa , NY 12019
(Signature of elative or Legal Rep. and Address)
Signed on this date: 1/5/05
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