Patterson, Elbert R TOWN OF. QcBuy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ]1B (tenet
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Date of Cremation ,J701
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Time Cremation Started
Time Cremation Completed (U . U c-
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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:
ELBERT R. PATTERSON MALE
(Name) Pm)
46 BIRCHWOOD DRIVR AU SABLE FORKS, NY 12912
(S ) (City) (State) (Zip Code)
who died on 1st day of ,TAN[J A R Y 20L0L
at CV/PH MEDICAL CENTER PLATTSB[JRG, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
JOAN PATTERSON 46 BIRCHWOOD DR4d[J SABLE FORKS, NY
(Name) (Address)
Relationship to the deceased WIFE
Name of Funeral Home M B CLARK, INC LAKE PLACID, NY
IMPORTANT:
I represent that to the best of my Imowledge,the deceased(has)or(has no)pacemaker,defibrillator,battery,battery pack,parer
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 said remains as directed,whether such claims or demands are or are not wholly
groundless,false or fraudulent.
�" 2310 SARANAC AVE. , LAKE PLACID, NY 12946
eNitm
(Address)
,A ,0y,"16 BIRCHWOOD DR. , AU SABLE FORKS, NY 12912
(Signature and Address of Relative or Legal Representative)
•
Signed on this date: 1/I J Oi b
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements_Please specify: PICKED UP BY F[JN'L DIRECTOR
If pulverization of cremated remains is requested,check here XX
Revision:January 1,2009