St. John, Sylvia TOWN OF QUEENSBURY
Pine View Cemetery find Crenintoriuni
21 Qunker Rond, Queenshury, NY. 12804-5902
(518) 745.4476 (518) 745.4477
http://w%vw.queensbury.net
Funeral Director: C
Name of Deceased: 5 t i L
Case Number: 3
Date of Cremation: !
Retort: ri 1-�- Fd l�
Time Cremation Started:
Time Cremation Completed: `zn_
Type of Container: �%U �� s?���[4J '� �Q'�t�l� ' l �J/ I -4%
Remarks: q
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" Hoene of Nnturnl Benuty ... A Conil Plnce to Live "
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:_
Sylvia May St. John Female
(Name) (Sex)
-- 97 rounty Rte 23, Hartford, NY 12838
(Street) (City) (State) (Zip Code)
who died on 5th day of August 2005
at rl Pns Fa 1 1 s Hncpi tal' r.1 ancFa1 1 NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Linda M. St. John 27 County Rte 23, Hartford, NY 12838
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Ga;-,-1:et- „ F,.,wa Heff . ine. -
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or Qaso
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 t#lem
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.
AAA, Carleton Funeral Home, Inc.
(Witness) (Address)
27 County Rte 23 Hartford NY 1838
(Sig atu o Relative or Legal Rep. and Address)
Signed on this date: