Pacheco, Eleanor A ti
TOWN OF QEB QLR9 "
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director ipiAl S Sr
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TOWN OF QUEENSBURY
PINE VIEW CEMETERY
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:
Eleanor A. Pacheco Female
(NAME) (SEX)
14 Academy Street Greenwich, NY 12834
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 27th day of April 2001
at McClellan Health Sysytems Hospital Cambridge, NY
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Miguel Pacheco Jr. 14 Academy Street Greenwich, NY 12834
Relationship to deceased Husband
Name of Funeral Home ''lynn Bros. , Inc. — Greenwich, NY
IMPORTANT
I represent that to the best of my knowledge, the deceased has or has 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 Jeason of or connected with the cremation of said remains as directed, whether
h cla eman wholly groundless, false or fraudulent.
80 Main Street Greenwich, '`Y 1283/,
(WIN SS) (ADDRESS)
(� 14 Academy Street Greenwich, NY 12834
(SIGNATURE OF RELATIVE OR/ILEGAL REP. AND ADDRESS)
April 28, 2001
Signed on this date: