Wilsey, Victoria TOWN OF" Q9B (..1g<../1
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director / 1leXtindoc
Name 'f(C+af“-1 �� �� Case # L3
Date of Cremation 9 ( z010
Time Cremation Started TOO �M
Time Cremation Completed /0: 15'dri
Type of Container tArc( houd ono- (� 14 f;r,stCSC
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 awtactxes Pike Vise CcematOikan,in aoeocdsnoe with and subject to Its Rules and Regulations to
cremate the remains of
Victoria Wilsey Female
(Name) (Sex}
1 Cloverleaf Dr . , Warrensburg, NY 12885
(Street) PIA (Stare) Code)
who died on 31 day of Jan zu 10
at Glens Falls Hospital
(Place) ( )
Name and address of nearest living reiative or name of person authorizing cremation:
Audrey B. Wilsey, same as above
(Name) (Address)
Relationship to the deceased Mother
Name ot Funeral Home Alexander-baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hi (has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I certify that I have foil power aid authorization to arrange for the aemadon of the remains end to drect the disposition of the
cremated remains,that any pa el possessions have either been remand or may be destroyed.and agree to protect,defend and
save harmless Pine��trr<t from any and ad dams and denim trims or*sieges which may be made against them
by reason of grimed with the aerate=of said seines as(boded,whether such claims or demands are or ate not wholly
groundless .blae orfraudulent.
pp ( Warrensburg, NY
• rtness),_Th (I'
/ (Address)
X �ji. `� "�'1'� Same as above
(Sign and Address Relative orlLegal Representative)
signed on this date: 2-1-10
Disposition of Cremated Hemains
I hereby direct Pine View Crematorium to dispose of the cremated remains as MOWS:
Masi to
other arrangements_Reese specify: FH will pick u p
If pulverization of cremated remains is requested,check here X
•
Revision:Jyiyr.7-,-z9174
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