Swinton, Courtney • TOWN Of Q5Jj[yB
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ,e cyii4 —..
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Name
u .e ` ' Q. Case #_
Date of Cremation3--, — (0
Time Cremation Started_ Pin
Time Cremation Completed II ,'
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Type of Container ac�j{Jaaj1C�1 ,� ��.�`�
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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 eut octaar Pine View Crematorium,m,in accordance with and si*4oct to its Rules and Regulations to
cremate the remains of:
cvve>v�y Sv'/v7J4✓ Female
(Name) (Sex)
29 Stacey St_ Warrensburg, NY 12885
( ) (CItY) (State) (Zip Code)
who died on 20th day of February iv 10
a 31 Bush St. , Glens Falls , NY 12801
(Place) (mess)
Name and address of nearest living tei live or mute of person aithorrang aemaean:
Evelyn Swinton 29 Stacey St . , Glens Falls , NY 12801
(Name) (Address)
Relationship tot the deceased Mother
NameotFufterdi me Alexander-Baker Funeral Home
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have tuff power add authorization to arrange for the aemaoon of the remains and to direct the disposition of the
cremated remain,that any personal possessions have ether been rammed or may be deed;,and agree to prOte t.defend and
save - Mew Cr cerium from any and all deists and dead for loss or demeges vittich may be made against them
by reason• •• .welt - - •- of sold rein etas as directed,whether such claims or demands ate or are not wholly
(W (Address)
arid Address of Relative or Legal Representathm)
sagnea on tnas Gate: February 21 , 2010
Disposition of Cremated Merriam
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mall to
other arrangements_please specify: FH will pick u p
If pulverization of aemated remains is requested,criedc here X
Revision:Jypd 004
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