Eggleston, Janet Funeral Director: ykx k6�)
Name of Deceased: ac vv
Case Number: -Z Z LA
Date of Cremation:
Retort: C4-t�w ra
Time Cremation Started:
Time Cremation Completed:
Type of Container: ��Z
Remarks:
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TOWN OF QUEENSBURY � 4
PINE VIEW CEMETERY l
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:
Janet Meriam(Holmes) Eggleston Female
(Name) (Sex)
Fort Hudson HCF Fort Edward,NY 12828-
(Street) (City) (State) (Zip Code)
who died on 25th day of May
at FORT HUDSON HEALTH CARE FAC. Fort Edward,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Joseph V. Eggleston 4930 Route 50 Gansevoort,NY
(Name) (Address)
Relationship to the deceased
Son
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (as 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 uch claims or demands are not wholly groundless, false or fraudulent.
68 Main Street, Hudson Falls, NY 12839
itness (Address)
(Si ature of Re ive or Legal Rep. and Address)
Signed on this date: