Drake, Jennifer r
TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crematorium
21 Quaker Road, Queenshury, NY. 12804.5902
(518) 74 5.44 76 (518) 745.4477
http //www.queensbury net
Funeral Director: A'�-I.-IE:A-o
Name of Deceased: a-N ki � ft LZ IN1,*K 1=
Case Number:
Date of Cremation: /i- o — 2.o v 15—
Retort: m F,C
Time Cremation Started: -3
Time Cremation Completed: o
Type of Container: C A a,)f3c4vJ d-we,,) - M'� '"� " 'Z .�- v A
Remarks:
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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
-rd subject to its Rules and Regulations to cremate the remains of:
— Jennifer Drake Female
(Name) (Sex)
2355 Burgoyne Ave. Apt. 13 Hudson Falls, NY 12839
(Street) (City) (State) (Zip Code)
who died on 6th_ day of November., 2005
at_
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Hudson Falls, NY 12839
u , 2355 Burgoyne Ave. Apt 13
�
(Name) (Address)
Relationship to the deceased husband
Name of Funeral Home --Tam-r-ieten iffinle-ra7H n
e.
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 certiy 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.
(Witness) (Address)
(Signature of Relative or gal Rep. and Address.)
1 �
Signed on this date: 1���