Laggan, Chance a '
TOWN OF QUEENSBURY
Pint View Cemetery nnrl Crentntnnuru
21 Qunker Rood, Qreenshury, NY. 12804.5902
(518) 745-4476 (518) 74 5.4477
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Funeral Director: Cib►\-,Z. k- E0
Name of Deceased: Gdl/G1= �1`�GE�r,°t ►�
Case Number:
Date of Cremation:
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Time Cremation Started: —.L �-- 'J b? ~�
Time Cremation Completed:
Type of Container: &17-'►3,K GKw-z� C AAC"
Remarks:
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TOWN OF QUEENSBURYZ-
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:
Chance Laggan Male
(Name) (Sex)
121 Main St. Apt 8 Hudson Falls,NY 12839-
(Street) (City) (State) (Zip Code)
who died on 31 day of
March, 2005
at Kingsbury, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Ann Moorman 121 Main St. Apt. 8, P.O. Box 685 Hudson Falls,NY
(Name) (Address)
Relationship to the deceased Mother
Name of Funeral Home
Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has Dno
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.
(W' ess) (Address) %,
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(Signature f Relative or Legal ep. an res
Signed on this date:
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