Luther, Clarice rroWN OF QUEEVBU9�YPINE VIEW CEMETERY ANDCREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director-9jgx,c
Name C L RA j P:' Case
Date of Cremation --�7-- �
Time Cremation Started
Time Cremation Completed&rl�j�� )
Type of Container G' S 7C �
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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:
CLARICE N. LUTHER FEMALE
(NAME) (SEX)
156 LAWRENCE STREET, APT309 SARATOGA SPRINGS . NY 12866
(STREET) (CITY) (STATE) (ZIP CODE)
who died on 26 day of April 20 01
at 156 Lawrence Street, Saratoga-Sprinas New York
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Mr. Donald Luther, 156 Lawrence St. Apt 309, Saratoga Springs,NY 12866
Relationship to deceased Husband
Name of Funeral Home Wi 11 i am J. Burke & Sons Funera 1 Hbme
IMPORTANT
I represent that to the best of my knowledge, the deceased has ortq acemaker 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.
William J. Burke & Sons
(WITNESS) (ADgara[o a Springs,Now York 12866
156 JaMel"91. Apt 309, Saratoga Springs
(SI A R OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 04/27/2001