Books, Patricia TOWN OF QUEENSBURY
Pine Vteto Cemetery nnrl Cremntortnm
21 Qunker Rond, Queenshttry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
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Funeral Director;
Name of Deceased:
Case Number:
Date of Cremation:
C e-1 7
Retort:
Time Cremation-Started: C7
Time Cremation Completed:
, III
Type of Container: ')�,+ C�+ � C... C,�
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Remarks:
2
Hoare o/ Nnturnl Benn A Gooit PInie to Ltue
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:
Patricia Lee Brooks Female
(Name) (Sex)
235 White Birch Estates Fort edward, NY 12828
(Street) (City) (State) (Zip Code)
who died on 1 2th day of April 2005
at Glens Fals Hospital
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Jennifer Gignac 14 Katherine Ave. , Queensbury, NY 12804
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home C-a-a- „te Funera=l Hm:eIne.
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,
wheth uch claims or demands are not wholly groundless, false or fraudulent.
V Carleton Funeral Home, Inc
(Witness) (Address)
11 Katherine Ave. , Queensbury; NY 12804
(Si nature o Relative or Legal Rep. and Address)
Signed on this date: