Teague, Lucius r. TOWN OF QUEENSBURY
~ Pine Viety Cemetery nnrl Crrntntorttrnt
21 Quoker Ronrl, Queensbory, NY. 12804.5902
(518) 745-4476 (518) 745.4477
hicp iiw%v\v queensbury net
Funeral Director: 1, arII-��n
Name of Deceased: L U(i V 5 ptih v e
Case Number:
Date of Cremation: 10 - U
Retort: Craw r�
Time Cremation Started: 3 u N • M
Time Cremation Completed: , `� h r4
Type of Container: ��,rot y�o ti r� w� wCxxi tr�w►.-t
Remarks:
LI
Hoiiir of .I\' ntitrnI Benitly ... A Con ,( PIncr 1n 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
a-nd subject to its Rules and Regulations to cremate the remains of:
Lucius Caswell Teague ale
(Name) (Sex)
Eden Park Health Care Ctr-, 170 Warren St, C;lens Pa11G NY 128A1
(Street) (City) (State) (Zip Code)
who died on the 6th day of May 2005
at Eden Park Health Care 170 Warren ci Glans lRai lsT-NY 1 -2201_
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
(Name (A dress)
Relationship to the deceased gnn
Name of Funeral Home Gas-leten Ru�11we-Ine.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or (hasDno
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 St. , Hudson Falls NY 12839
Witness) (Address)
Grove Ave, Glens Falls, NY 12801 j
(Signature of Relatfve or Legal Rep. and Address)
Signed on this date: /6/6)
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