Queiroga, Helen rrn
OF QUEE9�,-5r3Ur
PINE VTEW CEMETERY AND CREMATORIUM
�V�R ROAD, QljB SBURY
(518) 745.4.476 ' NEW YORK 12844
(518) 745-4.477
dame Funeral Director Cl
CPS v Cv
Case. 5� I
Dace Of Cremation 2 _ ��, o �
Time
Cremation Started
Time Cremation Completed
Type of Container C&. , -- -
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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 authorizes Pine View Crematorium,In accordance with and subject to Its Rules and Regulations to
cremate the remains of.
HPl Pn Qijt-J rc)ga Ft-ma 1 P
(Name) (Sex)
NY
(Street) (City) ( e) RIP �who died on 19th dayof December 20 08
at Indian River RPhah Ct_ rrnnvillPi NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
StPnhaniP Fran k 294 rilchriSf- Hill Road Hartford
(Name) z (Address)
Relationship to the deceased Daughter
Name of Funeral Home Carleton Funeral Home, Inc
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) has no maker,defibrillator,battery,battery Pads,power
cell,radioactive Implant or radioactive device in his or her body.(Circle One)
I certify that I have 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 sold remains as directed,whether such claims or demands are or are not wholly
groundless,fa or fraudulent.
- ) (Address)
(Signature and Address of Relative or Legal Representative)
Signed on this date: tAraa
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify:
If pulverization of cremated remains Is requested,check here X X
Revision:January 1,2009