Keech, Marjorie TOrWN OF QUEEN
�BUQ�Y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12904
(518) 745-4476 (518) 745.4477
Funeral Director
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TOWN OF QUEENSBURY Z,
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:
Marjorie M (Frost) Keech Female
(Name) (Sex)
Pleasant Valley Nursing Fac. Argyle, NY 12809-
(Street) (City) (State) (Zip Code)
who died on ist day of January 2005
at Glens Falls Hospital Glens Falls,NY
(Place) (Address)
Name and address of nearest living relative or name of person futhorizing cremations:
Curtis Keech 19 William Street Hudson Falls,NY
(Name) (Address)
Relationship to the deceased Son
Name of Funeral Home
Carleton Funeral Home Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to_arhrWejor the cremation
of the remains and to direct the disposition of the cren-wed-remains, that any
personal possessions have either been removed or rriaVtOOdbstroyed,--aWd.1agree
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 such claims or demands are not wholly groundless, false or fraudulgnt.
68 Main Street, Hudson. Falls, NY 12839
(Wi nes (Address)
f 19 William Street, .I4udson Falls, NY 12839
(Si nature a ati a or egal Rep. and Address)
Z
Signed on this date: Z �Y� '