St. Denis, Adolphe John owii UQueenJlu,nti
PINE VIEW CEMETERY awl CREMATORIUM
QUAKER ROAD, QUEENSOURY, NEW YORK 12801
(518) 798.472G
(518) 793-9777
Funeral Dirictor
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY �C5
di
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 798-4726 or if no answer Cemetery 793-9777
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:
Adolphe John St . Denis male
Name (Sex)
Roberts Gardens , North Queensbury , NY 12804
(Street) r,.:.._.
(State) (Zip Code)
who died on 30th day of December i9 91
at Glens Falls Hospital , Glens Falls , NY
(Place) (Address) ——
Name and address of nearest living relative or name of person authorizing cremation:
Mrs . Adelaide St . Denis , Bldg 210 A-2 Roberts Gardens , Queensbury , NY
(Name) (Address]
Relationship to the deceased wife
Name of the funeral home Carleton Funeral .Home , Inc .
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or has ncemaker 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.
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(Witness) � ��`�����• �Y
Signature g e of Relative or Legal R
• Carleton Fun ' l Home Roberts Gardens , Queensbury , NY
(Address) (Address)
•
Signed on this date / Z1 '5)0 61
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