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Park, Henry �^ TOWN OF QUEENSBURY Pine View Cemetery nnrl Crentn tort um 27 Qunker Rand, Queenshury, NY. 72804.5902 (518) 745.4476 (518) 745.4477 htrp llw\v\v queensbury net Funeral Director: .z b. k:z - --O C-1 Name of Deceased: Case Number: j Date of�Cremation: Retort: Time Cremation Started: I ,) , Time Cremation Completed: Type of Container: 14IA Remarks: tr�� /J ^, �/J `i c7//r C./CiC� l^- NG w A- �/'L0�.�f�/ r� 3© ek, i it n nI i r n I Ben it y A Crn l PInie In Ltue TOWN OF QUEENSBURY PINE VIEW CEMETERY & T 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 John Park Male (Name) (Sex) 42 McDougal Road Fort Ann, NY 12827- (Street) (City) (State) (Zip Code) who died on day of April �2 0o s` at Glens Falls Hospital Glens Falls, NY (Place) (Address) Name and address of nearest living relative or name of person authorizing cremations: Mrs. Sandi (Rowe) Park 42 McDougal Road Fort Ann, NY (Name) (Address) Relationship to the deceased Wife 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) x ? � (Signatu a of Relative or Legal Rep. and Address) Signed on this date: _14 42- 1 -2 a . -