Campney, George TOWN OF QUEENSBURY
Pint View Cemetery mid Cremntorinm
21 Qunker Ronr1. Qiteenshury, NY. 12804.5902
(518) 745.4476 (518) 745.4477
http i/w\v\v queensbury nei
Funeral Director: �Z- �^ r—• A"0
Name of Deceased:
Case Number:
Date of Cremation:
Retort:
Time Cremation Started:
Time Cremation Completed:
Type of Container:
Remarks:
G aG -���--1 ,v�y y-erg O `7
L 2D
" Home of Nnturnl Benuty ... A Goof 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:
eoLge D. Campney Male
(Name) (Sex)
16 LaBarge St. , HUdsonFalls, NY 12839
(Street) (City) (State) (Zip Code)
who died on 1 3th day of April, 2005
at 16 LaBarge St. , HUdson Falls, NY 12839
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mary Campney 16 LaBarge St. , HUdson Falls, NY 12839
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home Gar-leten Funeral-Here 3:ne
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (as
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.
Carleton Funeral Home, Inc.
(Witness) (Address)
�. �; _-- Hudson- Falls, NY
(Sign4 "re of Re ative or Lega4ep. ark, ddress)
Signed on this date: