HItchcock, Bertha R rf-n N OF QUEEVBURY
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Yk-rI
Name -�)-�cA _C � Case# Z�
Date Of Cremation
Time Cremation Started
Time Cremation Completed l 2) Q
Type of Container �'�u�1�c� rQp-Alter/ ,q y L_i -,I,
Remarks
At
y
12 'H/) t-211
)cep
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:
Bertha R. Hitchcock FPmnIP
(NAME) (SEX)
PO Box 56, Bakers Mills, New York 12811
(STREET) (CITY) (STATE) (ZIP CODE)
who died on the 22nd day.of February 2003
at Adirondack Tri—County Health Care Center, North Creek, NY 12853
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person authorizing cremation:
Daniel B. Hitchcock, Edwards Hill Road, Bakers Mills, NY 12811
Relationship to deceased Son
Name of Funeral Home Alexander Funeral Home, Inc. , North River, NY
IMPORTANT
I represent that to the best of my knowledge, the deceaser has no pacemaker in 'r 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 ims or demands are or are not wholly groundless, false or fraudulent.
--- - John Alexander, 3809 Main St. , Warrensburg, NY 12885
ITNESS) (ADDRESS)
�el B. Hitchcock, Edwards Hill Rd, Bakers Mills, NY 12811
(SIGNATURE OF RELATIVE OR LEGAL REP. AND ADDRESS)
Signed on this date: 02/24/2003