Havens, Eleanor ?��NE YTEW EM QuErEgq
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��•�R ROAD. �TE'R Y ^tYt,� C R E M E TO R i U M�' �J
(518) 745 44 6 SHVRY, "—W YORK 17804
(S18) 745••4.477
FI Funeral Director G 4rI
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'd a D! Crema Caner Z�b
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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 urderslgned requests and aLgd n b es Phre View Cremetadum,in accordence with ero subject to b Rubs and Regulations to
dentate the remakta at
Eleanor M. Havens F
(Name) (Sex)
3.5 LaBarge Hudson Falls NY 12839-
(Street) (City) (State) (ZJp Code)
Wv died on d9Yd 06/06/2009 20_
at Glens Falls Hospital Queensbury NY
(Place) (Address)
Name and address of rtaarast living relative or name of person authors aemat+on:
Jamie Smith / / !Jh , /0e11 -
(Name) (Address)
ROWWM hiP to the decae98d Granddaughter
Norm d Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the bast of+try latowiedge,dw doaeew d(tw) {has rho) matter,ddbrNeW.battery,battery Peck,power
call,radioecdve impMrtt or radfoacrive devioe In his or her body.{
I Oar*fiat i have U poorer and au&Kw zntion ID arango ror the cremarlon of the remains end to dkW the dispoekion of the
crenu tpd remains,that any pemK mal poseaasiorts have aifier been rarrtoved or may be deft ,end agree to protect,defend and
save harmless Plra View Crematorium tram any and all claims and demands for bw or damages whtch may be made agwag them
by reason d or corrected wkh Ow wwwA on of said remahts as dkWed,whether such chin ar demands are or ere riot wholly
false or fraudttlert.
J 68 Main Street, Hudson Falls, NY
(witness) {,4dtirass)
(signature widAddFew of ReWNe or Legal Representellve)
signed on this date: -J U,n e- —70 a C)o Cr
Dbpoeltion of Crarttated Remel ne
I hereby direct Pine View Cranewrium to dispose of the cremated remains as tN ws:.
Mail to
Other arrangernertts-Please Wec fy:
If pAveraation of cremated remains is requested,dteat here XX
Pevtskrt:AprN 18,2007