Myron (Baker), Helen Mae • L O T1NOfF QEcB (_,1IKy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Z-f.
Name e[ Case #
Date of Cremation rebtve,r a 70)0
Time Cremation Started c6; 3p if7
Time Cremation Completed 10 : 30 fl61
Type of Container Gcrtl lo4td dr
Remarks :
. 110
10 00 An
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 soil 1bes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
Helen Mae (Baker) Myron F
(Name) (Sex)
Fort Hudson HCF Fort Edward NY 12828-
(Straet) (City) (State) (Zip Code)
whodiedon 30th dey of January 20 1 0
at FORT HUDSON HEALTH CARE FACFort Edward NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremation:
James Bucher 13 Seventh Ave. , Hudson Falls, NY
(Name) (Address)
Relationship to the deceased Friend
Name of uneraiHotrte Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) . (hes no)pacemaker defibnliatar,battery,battery lam,power
cell,radioactive implant or radioactive device in his or her body.( • • One)
1 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 cairns and demands for loss or damages winch may be made against them
by of or connected with the cremation of said remains as dieted,whether such debts or demands are or are not wholly
41/1
,false or fraudulent.
� ^ 68 Main Street, Hudson Falls, NY
�'� /(Y mess) (Address)
7 g..... Seventh Avenue, Hudson Falls, Ny
(Signature,y(
and Address of five or Legal Representative)
Signed on this date:
•
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 XX
Revision:April 18,2007 •