DeMello, Gilbert /Y
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 Een-Wins of:-
Gilbert DeMello
male .
(Name) (Se
3310 State rte 4, Kingsbury, NY 12839 .: -
(Street) (City) (State) (Zip Code)
who di 1 2th Nov. Xt6ed on day of �.
at 3310 State Rte 4, Kingsbury, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Irene DeMello 25 West State St. , Glens Falls, NYC 12801
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Ga--,.>:eten-R al He e Ino.
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 4 �
by reason of or connec ed with the cremation of said remains as directed,
whether such claims r emands are not wholly groundless, false or fraudulent. j
I
i
Carleton Funeral Home, Inc.
(Witness) (Address)
, /J N��JA _, M, 25 West State St. , Glens 'Falls, NY
(Signature of Relative or Legal Rep. and Address.)
Signed on this date:
I
TOWN OF QUEENSBURY
Pine View Cemetery nnrl Crematorium
21 Qunker Rond, Queenshury, NY. I2804-5902
(518) 745-4476 (518) 745.4477
http://w%vw.queensbury.net
Funeral Director: G 0,\-2� t-,�
Name of Deceased: -vim 1-� - /) � d
Case Number: <:6 L4
Date of Cremation: r— ) 1 — l — 7--,o 4
Retort: l'i r�
Time Cremation Started: 10 -ts- �'-VII-
Time Cremation Completed: ____ ��"/ [✓'�.
Type of Container:
Remarks:
t 1 3
l -55 11 c
J2 � S� y