Washburn, Raymond K —J4---47
TOWN OF QUEENSBURY �/1
PINE VIEW CEMETERY U
A
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:
Raymond K. Washburn Male
(Name) (Sex)
Daniel ' s Road Saratoga Springs , New York 17RF6
(Street ) (City) (State) (Zip Code)
who died on 5 day of November 19 06
at Saratoga Hospital _ Saratoga Springs, New ynrk, l2R66
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Sue Ann Rvans 21_08 trwnlinP Rd, Geneva. New York. 14456
(Name) (Address)
Relationship to the deceased Daughter
Name of Funeral Home Wm. J. Burke & Sotl,s Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or
has no pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization ter 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 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.
7 2R North Broadway, Saratoga Springs. NY.
(Witness) , (Address)
// aka -
(Sign u d of Relative or Legal Rep. and Address)
igned on this date :