Austin, Virginia Rosamond • TOrk1N OfF Q5BJR9
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name r-50114. A t,r Case # ` 1,
Date of Cremation I-ti it/ ZUIQ
Time Cremation Started it) �
Time Cremation Completed `1 S(-)ti
Type of Container he,;t;,c 0214 T- rI t, (6 -(
Remarks :
MPTti S. /u 1'1 rvo/h
SL
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury, New Yak, 12804
Cemetery Office: (518)7454476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and a i ho thes Pine View Cremetorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
Virginia Rosamond Austin F
(Name) (Sex)
Fort Hudson HCF Fort Edward NY 12828-
(Street) (City) (State) (Zip Code)
who died on 12th day of February 2010
Glens Falls Hospital Glens Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
7 Me,-1(,, 51 / C(r✓rJ 1-;(1jj i (Z oI
(Name) (Address)
•
Relationship to the deceased S o n
NamedFun iHcme Carleton Funeral Home, Inc.
IMPORTANT: -f 1
I represent that to the beet of my knowledge,the deceased(has)oc(has no)pacemaker,defibnlietor,battery,battery per,power
cell,realoeebve implant or radloective device in his or her body.(CbLslp.One)
1 certify that I have full pow and authorization to ananpe for the cremation of the remains end 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 fix toss or damages which may be made against them
by -- • of or connected with the cremation of said remains as directed,whether such Balms or demands are or ere not wholly
• • :,false or fraudulent.
I „ 68 Main Street, Hudson Falls, NY
i ��v' / ) //, (Address)) //
/'/: ���ZJ ? t i tiulc S� GI- 67/ //S, vj
(Signature and Address of Relative or Legal Representative)
Signed on this date: //I ( i'((v
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains es follows:.
Mail to
Other arrangements-Please specify:
if pulverization of cremated remains is requested,check here XX
Revision:April 18,2007 •