Johnson, Ruth I ,
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Rua J�Hsa Case # y(g
Date of Cremation re Z� I Z2IO
Time Cremation Started r'
Time Cremation Completed jv; Uqb
Type of Container 6-1 11
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 authorizes Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Ruth I. Johnson Female
(Name) (Sex)
9 Henry St. , Warrensburg, NY 12885
(Street) (City) (State) (Zip Code)
who died on 17 t h day Febof 20 10
at Glens Falls Hospital
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
Wendy A. Peluso , 17 Henry St . , Warrensburg, NY 12885
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Alexander-baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(hifsYA(has no)pacemaker,defibrillator,battery,battery pack,power
cell,radioactive implant or radioactive device in his or her body.(Circle One)
I certify that I have full.power a uthorization to arrange for the cremation of the remains and to direct the disposition of the
cremated remajna that any I possessions have either been removed or may be destroyed,and agree to protect,defend and
save harm)ess Pine View atorium from any and all claims and demands for loss or damages which may be made against them
by of or con with the cremation of said remains as directed,whether such claims or demands are or are not wholly
g dless,false udulent.
�' Warrensburg, NY
��. (Witness) D
(Address)
X b2jIAA ; -Y •.. ,°w� Same as above
(Sign ure and Address of Relative or Legal Representative)�-E"
Signed on this date: \\ 2-17-10
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
Mail to
Other arrangements-Please specify: FH will pick up
If pulverization of cremated remains is requested,check here X
Revision:January 1,2009