Stetson, William C:) --A TOWN OF QUEENSBURY
Pine View Cemetery and Cremntonum
21 Qunker Road, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director: «-
Name of Deceased: ��[ k L f J���S d r
Case Number: Z `�
Date of Cremation:
Retort: T!
Time Cremation Started:
Time Cremation Completed:
Type of Container: � ��� �-:3 d A,62&,
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,
accordance with and subject` to its Rules and Regulations to
cremate the remains of:
William Stetson Male
(Name) (Sex)
256 13th Lake Rd. , P.O. Box 110, North River, NY 12856
(Street ) (City) (State) ( Zip Code )
w h o died on 19 th d a y of March )A 2005
at Adirondack Tri-County Health Care Facility, North Creek, NY
(Place) (Address )
Name and address of nearest living relative or name of perscn
authorizing cremation :
Barbara Stetson, 256 13th Lake Rd. , P.O. Box 110, North River, NY 12856
(Name ) (Address)
Relationship to the deceased Spouse
N a m e o f F u n e r a l H o m e Alexander Funeral Home, Inc. , North River, NY
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 , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against them ov
reason of or connected with the cremation of sal rem in as
directed, whether such claims or demands are or are�', no it \
groundless, false or fraudulent . \
John S. Alexander, 3809 Main St. , Warrensburgh, NY 12885 L "
(W ' t ss ) (Address )
! f
256 13th Lake Rd.-, P.O. Box 110, North River, NY 128'
r (Signature of Relative or Legal Rep. and Address)
Signed on this date :
S