Smith, Gertrude F TOWN OF OUEENSBURY �
PINE VIEW CEMETERY I
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:
FPma1Q
(,, rtrudc F. Smith (Sex)
(Name)
133 Hamilton St .
Saratoaa Springs NPw Ynrk, 12866
(Street )
(City) (State) (Zip Code)
who died on 29
day of nrtobcr l9�_
at I Hamilton SLLeeL x Saratoga Springs, NY .
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
e, N y, 12211
(Name) (Address)
Relationship to the deceased NiPrP
Name of Funeral Home Wm. J . Burke & Sons Funeral Home
IMPORTANT: knowledge, the deceased has or
I represent that to the best of my (Circle One)
has no pacemaker in his or her body.
I certify that I have the full power and authorization to arrange
for the cremation of the remains and to direct
possessionsshaveteither
of
the cremated remains, that any personal and a ree to protect, defend
been removed or may be destroyed, 9
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 or are not wholly
groundless, false or fraudulent.
j �j�, roadwa ,
Saratoga Springs , NY.
' tnes > � (Address>
of Relative or Rep. an Address) Lr 6t
(Signaturer Le /
Signed on this date :