Cherney, Jacqueline h
W OF QUEE9�SOU(�y PINE NIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY NEW YORK 17804
(518) 745.4476 (518) 745'.4477
Funeral f/
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Tame Cremation Started
T 'cme Cremation Completed p
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and auftwizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremete the remains oP
Jacqueline Cherney F
(Name) (sex)
175 Broad Glens Falls NY 12801-
(Street)0 3/14/2 0 0 7 (city) (State) (zip Gods)
who died on day of 20_y__
Glens Falls Hospital Glens Falls NY
at
(Pkm) (Address)
Name and address of nearest Ruing relative or name of person authorirrinp cremation:
Ms. Amanda Cherney Route 196
(Name) (Address)
Reiationshp to the deceased Daughter
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I rapresent that to The best of my bwwledge,the deceased(has)or(has no)peoemaker,daAbrfllator or any other battery operated
device in his or her body. (Ckde One)
I corny that I have hA power and eudxwbvtion to arrange for the cremation of the remains and to dined the disposition of the
cremated remains,that any personal possesslorhs have either been removed or may be destroyed,and agree to protect,deibnd and
am harmless Pine View Crernakw n from any and all claims and demands tar foss or deraagas which may be rnade against them
by reeson of or connected with the cremation of said remains as directed,whedw such daims or demands are or are not wh*
Use or frauduterht.
-4� S 6 9 � I�L� A �
(Signhature and Relative or Legal R )
7
/Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as fdbws:
MON to
Other emarnpementa-Please specify.-
if puhwtz Lion of cremated remains Is requested,dhedc hens XX
Revision:January 1,2006