Stevens, Gus 1
TOWN OF Q UEENS23 UR Pine Viers' Ceuretery and Cr0114toriunl Y
11 Quaker Road, Qneenshury, NY. 12804.5902
(518)745.4476
hirp:i/www.queensbu (S 18) 745.4477
bury.
Funeral Director.
Name of Deceased:
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Case Number.
Date of Cremation:
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Retort: r4
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Time Cremation Started: tZ;kv
Time Cremation Completed: 3`•cx,,0)
TYPe of Container.
Remarks:
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" HO "ne of Nntural 8enuty ... A Gnn11 Plnc•e 10 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:,
Gus C. Stevens male
(Name) (Sex)
52425 Firehouse Way Fort Ann, NY 12827
(Street) (City) (State) (Zip Code)
who died on 12th day of June 2008
at _5242 Firehouse Way, Fort Ann, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Tina Haviland, 375 Hadlock Pond Rd, Fort Ann, NY 12827
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Gar cte FwieEal Here ins
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 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.
pl ,00�
Carleton Funeral Home, Inc.
(Witness) (Address)
Fort Ann NY
(Signature of elative or Legal Rep. and Address.)
Signed on this date: