Monroe, Wilford 1 _
L O wN OF QUEEN.
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director .��X/g/�,���
Name lj j k )`::�66D AOCN/?d,- Case # 911A9
Date of Cremation 07�
Time Cremation Started
Time Cremation Completed f FIQ i9 / M r
Type of Container
Remarks :
/tin,
lam ,` /,*7�
TOWN OF QUEENSBURY
PINE VIEW CEMETERY ,
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone(518) Crerrt4t9rigM;l 745-4477;(if no answer)
Cemetery 745-4476
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance with and subjec�
to its Rules and Regulations to cremate the remains of:
Wilford J. Monroe Male
(NAME) (SEX)
454 County Route 11, Bolton Landing, New York 12814
(STREET) (CITY) ? (STATE) (ZIP CODE)
who died on the 28th day of April 2001
at His Hone — 454 County Route 11, Bolton Landing, New York 12814
(PLACE) (ADDRESS)
Name and address of nearest living relative;or name of person authorizing cremation:
Mrs. Rita Monroe,. 454 _County route 11, Bolton Landing, New York 12814
Relationship to deceased ! :Wife
Name of Funeral Home Alexander Funeral Home, Inc.
IMPORTANT
I represent that to the best of:my:knowledge,the deceased._ .has no pacemaker in his XW
body. (CIRCLE ONE)
I certify,,that I. have Jhe,full pQWer,and:a44g.trizabon�to aria g..,)•Gr�.the.cremabon of the remains and
to direct the.djspositton;p# a g� rpie. r�t1 (ne;€titrlypo al:pgssessions have either been
removed or may be destroyed, and agree to`protect, defO�_;.andisave: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 demarlds are or are not wholly groundless, false or fraudulent.
Clifford R, Gates,, 3809 Main St. , Warrensburg, N.Y. 12885
(WIT S) ,(ADDRESS)_
_,Rita Monroe, 454 County Route, 11, Bolton Landing, N.Y. 12814
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: April 29, 2001