Belden, Mason Sr. O
YI QUEE9�,(5�BUT
PINE CEME
�J
Ems' TERY AND CREMATORIUM
QU"-ER ROAD, Q(JEENSBURY, NEW YORK 12804
(518) 745.4476 (518) 745*•4.477
Funeral
Director
Name
l
tc( Y1
tisa
Case;r —JAIL
=a • e Of Cremati.on
' :me Cremation Started
j -
' • Te Cremation Completed IQ - 3v
rye of Container ('�o+l, Cc,�K�t
Remarks S �iflSr
u .2
sal
10 � o
ro®L is : 3o M
i
I
I
i
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 urWersipned requests and aultwrtres Pine View Crematorium,in accordance with mid subject to its Rules and Regulations to
cremate the remains oP.
Mason Belden M
(Street)0 3/31/2 0 0 7 (City) (Slats) (Zip Code)
who died on day of 20__
Glens Falls Hospital Glens Falls NY
at
(Place') Oddr'ess)
Name aW address of nearest Wing relative or name of person autiwrtdrg cremation: (�
Jamie Belden
(Name) (Address)
Reladona*to the decessed Daughter
Name of Funeral Home Carleton Funeral Home, Inc. T_
IWORTAW:
I ralmesm that to the buster my larowledge,the daoessed(has)or(has no)pacemeW,delib balm or any other battery operated
device in his or her body. (Girds One)
I comfy that I have U power and sudtorb ation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possesslons have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Cranatodurn from any and A dakns and demands far loss at dernaga 1 which may be made against them
by of or corntuxled with the demotion of said remains as
as directed,wh/etther such tisims or demands ,( ire not
wh*
(v+ ) ( )
(Signature and Address of Relative or legal Reprtnre)
Signed on finis date:
Disposition of Cremated Remains j
I hereby direct Pare View Crematorium to dispose of the cremated remains as follows.
MaH to
Other arengarrrerrts-PMM specify; _
I
if pulverbalion of cremated remains Is requested,d+edc he XX
re
Revision:January 1,2006
I
I