Squires, Charles A rl-nrKN OF QUEEVBUr�Y
PINE VIEW CEMETERY AND CREMATORIUM �
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/
Name t) i R)E7�5 Case # p
Date of Cremation 0
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks :
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY er
&
CREMATORIUM
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:
Charles A. Squires Male
(NAME) (SEX)
25 Commercial Ave. , Warrensburg, New York 12885
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 27th day of January 2000
at The Glens Falls Hospital - ER, Glens Falls, NY 12801
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Rudy B. Squires — 4 Third Ave. , Warrensburg, NY 12885
Relationship to deceased Brother
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT
I represent that to the best of my knowledge, the deceased; as no pacemaker in his4x_iW
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 cl m r de a re or are not wholly groundless, false or fraudulent.
3809 Main St. , Warrensburg, NY 12885
(WITNESS) DDR S)
V
4 Third Ave. , Warrensbug, NY 12885
(SI TURE O LATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 01/28/01