Griffin, Lawrence B TOWN OF Q $B'UR
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director G Pi\21.,f= kO f�
Name 4-Pki ; -4 Case # 2 -2, Ca
Date of Cremation ,5 - le) Z Q d °-1'
Time Cremation Started 1fj Q 14
Time Cremation Completed / / 5 P
Type of Container6i4- d gd -Loon) /(/tv4� I\I
Remarks :
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TOWN OF OUEENSBURY
PINE VIEW CEMETERY
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:
(Name) (Sex)
Fort Hudson Health Care Facility, NY 12828
(Street ) (City) (State) (Zip Code)
who died on 5th day of May INC 2004
at Fort Hudson Health Care Fari1ity
(Place) (Address)
Name and address of nearest living relative or name of person
authorizing cremation:
•
Dorothy Griffin The Oaks . A ard
_ L l
(Name) (Address)
Relationship to the deceased wife
Name of Funeral Home Carleton Funeral Home. Tnr , hR Main St . ,
Hudson Falls, NY
IMPORTANT:
I represent tha_t to the best of my knowledge, the deceased has or
has (no paceina in his or her 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, 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.
(Witness) (Address)
(Signature of Relative or Legal Rep. and Address)/
Signed on this date : ` / , ,2200