Rice, Marjorie TOWN OF QUEENSBURY
Pine View Cemetery and Cremntorlll Rl
21 Qunker Rond, Queenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
htrp//www.queensbury net
Funeral Director:
Name of Deceased: IA A Cl-�Co t�-� t � �c, F, _
Case Number: (-
Date of Cremation: '� — �T c)
Retort: C A'& .W
Time Cremation Started: 3 O
Time Cremation Completed: 3
Type of Container: Q-) \7jd A4 A\w ��� t�-�� '17
Remarks:
��� L•. ro0oyty I-VI
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" Nome of NntitrnI Beauty ... A Good PInie Io Ltue '
SENT BY: ; 802 492 3028; MAR-8-05 10:44AM; CAGE 1!1 03/00/2005 03:3b 5186422322 ROBERT M KING PH ( r V
PAGE 02
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road,Queensbury. New York 12804
Phone(518)Crematorium 745-4477(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and autnorzes Pine View Crematorium, in accordance with and subject
to its Rules and Regulat►ons to cremate the remains of.
Mar,'oaie Bentley Rios Ferrale
(NAME) (SEX)
85.34 Cold River Rd. Shrewsbury, VT 057118
(STREET) (CITY) (STATE) {ZIP CODE)
who died on I 7 day of March
at G1ene 'Fal1s HosDiWal , 100-10e Park St. G-lens Falls. NY 12301
(PLACE'I (ADDRESS)
Name and a0dress of nearest living relative or name of person authorizing cremation:
David; Rice,853 Cold River R•? 9hrP3jghury.V1 05"'38 _
I
Rslationship�to deceased son
Name of FLmeral Home Robert M. King Funeral Home
I MPORTA Nt
I represent that to the best of my knowledge, the deceased LIM or hA.Vc pacemaker in his or her
body (CIRCLE ONE)
I comity!hat J have tl^e 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 mother been
removed or may be destroyed,and agree to protect, defend and save harmless Pine View
Crematorium from any and all clairrs and demands for loss or damages which may be made
against therh by reason of or connected with the cremation of said remains as directed,whether
such claims or demands are or are not wholly groundless. false or fraudulent.
Shrc�cJ`�btc! J�U
(WI T N E S Z(ARESS)
V�
(SI NATURE OF RELATIVE a EGA' REP AND ADDRESS) J,. .0 7
Signed on t1is date:
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