Mussen, Theresa J -
rnRN OF. QUEEVBU9KY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director k 14
Name L r45y N�o55it� Case # 3�.�
Date of Cremation 2005
Time Cremation Started i2; ph
Time Cremation Completed
Type of Container ov� �� ,� CtQAIIFbc-(O 5Lr6w CASE
Remarks :
MA17N )"b 6Qh NMogE:- ('26 rU l
zocu P►�
ZN6
I
I
Town of Ckmnsbury
Rine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New York, 12804
Cemetery Ofka: (518)745-4476, Crematorium. (518)745-4477
Authorization to Cremate
The underttipned mW er<ffi and atrtttorites pkm View Ownekwiunt,in aaoordenoe wlth and su*d to ks Rules and Regt tioos to
crrxttete the remakes of:
THERESA L. MUSSEN F
(Name) (S"
Fort Hudson Health Care Facility Fort Edward NY 12828-
(Straet) (City) ( (ZJp Code)
Y*o died on 19th day of Aug,ust 20 09
at Glens Falls Hospital Glens Falls NY
( ) ( )
Nerne and address of on me Irving rabOve or ttum of pataon sLOxwb tp c effmMon:
Janice L. Finnegan 1124 Ridge Road, Queensbury, NY j
(Name) (Address)
Rtiiatlorteltip to the deceased Daughter
Name of Funeral lkx. Hamilton Funeral- Home, Inc.
IMPORTANT:
i
I represent tug to the bed of my latowtedge,the deceased(has) ro4acemaker,delNxt' SW,battery,battery ie,power
cell,redloecdve implant or radtoecOve device In his or her body.(C
I ow*that I have AA power end audwrindlon to arrange for the cremedan of the rer m is and to Brea the disposohm of the
cr m*W Termed,that arty pmeonhl poseessbm have eklmr been removed or may be destroyed,and agree to protect defend and
sere hermWa Pt o View Cremekoftm from arty and al ciaitns and demerds for Im or damages whldt may be made egWat them
by reason of or cannarted wkh drs cremation of acid romains as d1rected,wtre W such chime or derearrds are or are not wholly
faW
68 Main Street, Hudson Falls, NY
( ) (Address)
1124 Ridge Roadr Queensbury' Ny
(Signature and Ad&fts of Reieeivos olWW Representative)
Signed on thIS dme: y p I 0 /
I
I
Disposkon of Cremated Remains
1 hereby direct pine View Crematorium to dispose of the cremated remetns as follows:.
Mail to
other arrertgemerrta-Please specify:
If pAverkation of crenated rerrtem is mWesied,dm&here XX
it
RavWm..April 18,2W7