Pelton, Henry Jr. TOWN OF QUEENSBURY
Putt View Cemetery niid Crentntonum
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http//w%v\v qucensbury net
Funeral Director: C-4 NL-1v -
Name of Deceased:
Case Number: �e'
Date of Cremation: �- - G 'LG U 5
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container:
Remarks:
"T
�47
Home of Nnturnl Benuty ... A Good Plnie to Live
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:
Henry Pelton, Jr. Male
(Name) (Sex)
13 Bacon Street Glens Falls,NY 12801-
(Street) (City) (State) (Zip Code)
who died on day of
February) Z o o S'
at Glens Falls Hospital Glens Falls,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mr. Hank Pelton 12 Elizabeth Street Glens 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 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 such claims or demands are not wholly groundless, false or fraudulent.
68 Main Street, Hudson Falls, NY 12839
(Witness) (Address)
Orignature of-Melative or Legal Rep. and Address)
Signed on this date: )--q -0-�l