Najer, Nancy A TOrkl) OQUEENS'Br(ify
PINE VIEW CEMETERY AND CREMATORIUM
• QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director
Fame ,
Case# `j Y(3
Date Of Cremati.on I - 07
Time Cremation Started j 12u 11
Time Cremation Completed 6,
Type of Container (c,r_ 70,std n
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Remarks
h-'10 PM
No'E. I : 16
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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:
Nancy A. Najer Female
(Name) (Sex)
58 Theriot Ave . , Chestertown, NY 12817
(Street) (City) (State) (Zip Code)
who ded on 28th day of Dec. 20 06
at Glens Falls Hospital
(Place) ( )
Name and address of nearest living relative or name of person authorizing cremation:
Trevor LaBarge , Same as above
(Name) (Address)
Relationship Husband
�
Name of Funeral Home Alexander-Baker FH, Warrensburg, NY
IMPORTANT:
I represent that to the best of my knowledge,the deceased(tf Kr(has no)pacemaker,defibrillator or any other battery operated
device in his or her body. (Circle One)
I 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 pe essions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine V,iear m from any and all claims and demands for loss or damages which may be made against them
by reason ofgi wed ' he cremation of said remains as directed,whether such claims or demands are or are not wholly
groundless:false or lent.
X - yftness
, .---1„,---, S as ..a s,v e
_ -(Signature and Address of or epreserdaWe)
Signed on this date: 12-2 9-0 6
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 1,2006