Sherwood, Betty C TOWN OF Q $ BQiy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director MN5610
Name Bc\"ki 5ktrwvpG1 Case # 7
Date of Cremation Lt,i9 n 7010
Time Cremation Started (6,; OO Am
Time Cremation Completed iOA Ati
Type of Container /ArL1t,Garcd Q,r ' ,01- C,u-C
Remarks : cRAwaoR0
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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:
Betty C. Sherwood Female
(Name) (Sex)
356 Weller Rd. , Fort Ann, NY. 12827
(Street) (City) (State) (Zip Code)
who died on 13th day of February 20 10
•
at Glens Falls Hospital, 100 Park St. , Glens Falls, NY.
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Delia Sherwood, P.O. Box 105, Comstock, NY. 12821
(Name) (Address)
Relationship to the deceased Daughter
Name ofFuneraIHome Mason Funeral Home, Fort Ann, NY. 12827
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has)or :. no maker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Ci •: •ne
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 frauduliOi
(Address) dfir
/1.Lti)770Za, same as above.
(Signatu and Address of Relative or Legal Representative)
Signed on this date: Feb. 14, 2010
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
Revision:January 1,2009