Liner, Carolyn Frances """MN 0F QUEEM
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEEINSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral DirectorDO &ttr—, ✓®P��'
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Date of Cremation _ Z U p 001
Time Cremation Started ' " 1
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Time Cremation Completed
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Y Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 (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:
Carolyn Frances Liner Female
(NAME) (SEX)
131 Lawrence Street, Saratoga Springs, New York, 12866
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 2 day of June 2000
at Wesley Health Care Center, 131 Lawrence St. , SS, NY, 12866
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Marilyn D. Dockum, 48 White Street, Saratoga Springs , NY, 12866
Relationship to deceased Niece
Name of Funeral Home William J. Burke & Sons Funeral Home
IMPORTANT
I represent that to the best of my knowledge, the deceased has o as no cemaker 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 deman are or are not wholly groundless, false or fraudulent.
( ESS) (A DRESS)
X I
(SIGNATU OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 5