Chadwick, Elizabeth R rro q+N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director/(I,L
Name 7—/�C/ / IT c, j ,Q4J iCfrCase # -�
Date of Cremation �oZ. ` o2+CSC�1Q
Time Cremation Started '�;,;® "M
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Time Cremation Completed_](Ia a , M
Type of Container,j"9��/ D 16 / r /
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TOWN OF QUEENSBURY
_ — PINE VIEW CEMETERY
CREMATORIUM J /
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:
ELIZABETH R. CHADWICK FEMALE
(NAME) (SEX)
12832
(STREET) (CITY) (STATE)' P CODE)
who died on LOTH day of DECEIVER 20 00
at 6410 ST. RT. 149, GRUILLE, W 12832
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
RAYMM N. CFKMICK
Relationship to deceased HUSBAND
Name of Funeral Home M. B. KILMER FUNERAL HOME
IMPORTANT
I represent that to the best of my knowledge, the decea e0hasor s no pacemaker 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) im,
F124k41-0-a
SIGNATURE OF RELATIVE OR LE AL REP. AND ESS)
Signed on this date: j aT I I L' 0 -D