Bell, Gordon F TOWN OF Q5 \f$B'UR9
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director rit;tc`
Name —lurclo , z Case # 1�
Date of Cremation tZ o IS 20K)
Time Cremation Started 3 U , \ i
Time Cremation Completed 101 50 /M
Type of Container (;)1C oord a tivf)P-0 f it'St' (SSC
Remarks :
' iic trIvLd6 7:2C' 11
ci
5U��1
/07/0 vqM
79
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Gordon F. Bell male
(Name) (Sex)
19 Cartier Lane Fort Ann , NY 12827
(Street) (City) (State) (Zip Code)
who died on 12th day of February, 2010
at 19 Cartier Lane Fort Ann, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Gina Sabo 235 County Rte 16, Fort Ann, NY 12827
(Name) (Address)
Relationship to the deceased daughter
Name of Funeral Home Carleton Funeral Home Inc.
IMPORTANT:,
I represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
I certify that I have the 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 not wholly groundless, false or fraudulent.
Hudson Falls, NY
c:wime (Address)
Fort Ann, NY
(Signature of Relative or Legal Rep. and Address.)
Z �/1/1 ,
Signed on this date: ��