Herrman, Martha L O I N OF QUEENY5BU9U
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
.41
Funeral Director 1-L �o
Name/ /7// //�/► //I Case #
Date of Crematicn
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks:
OX
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
r �
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:
Martha A. Herrman Female
(Name) (Sex)
10 Ashe Drive Warrensburg New York 12885
(Street ) (City) (State) (Zip Code )
who died on 29th d a y o f December 19 98
at Porter Hospital Middlebury, Vermont
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation :
Evelyn L. Pullen 12 Meadow Way Middlebury, Vermont 05753
(Name) (Address)
Relationship to the deceased niece
Name of Funeral Home Alexander Funeral Home
IMPORTANT:
I represent that to the best of my knowledge, the deceased XXXXoX)ft
has no pacemaker inXKX)i(X *Xher body. (Circle One)
I certify that I have the 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 , defenc
and save harmless Pine View Crematorium from any and all claims
and demands for loss or damages which may be made against then b,,-
reason_ f or connected with the cremation of said remains as
direfted whether such claims or demands are or are not wholly
gro ndl s , false or fraudulent.
Wi ness ) l (Address)
x S' El-�
(Signs te
of Relative or Legal Rep. and Address)
Signed on this date ; January 2, 1999