LaValley, Paul OF QUEEN
U,
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
a 7 e ��UG., y 1r��� Case#
aJ, e Of Cremation
. _Te Cremation Started
:7e Cremation Completed_
';. pe of Container �,�
K,emarks �-
si
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road,Queensbury,New York, 12804
Cemetery Office:(518)745-4476, Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and auftftes Pine view Crematorium,in a000rdance with and subject to its Rules and Regulations to
cremate the remains of:
Paul Andrew LaValley M
(Name) (sex)
238 Main Street South Glens Falls NY 12803-
('v 6/21/2 0 0 6 (City) (State) (Zip Code)
who died on day of 20
Glens Fails ospi a G ens Fails
at
(Place) (Address}
Name and address of nets W"reWw or nano of person auexxtdrg cranaliat:
Michael Preston 21 East Notre Dame St, Glens Falls, NY
(Name) (Address)
Reiationship to the de r eP P q 1 s o n
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
i represent that to the best of my bm wiedge,the deceased(has)or(has no)peoerntiker,dafhdilatcr or any odter bettary operated
device in his or her body. (Ckda One)
i cerW that I have fu1 power and suAhorbstim to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,that any personal possessions have either been remo and or may be destroyed,and agree to protect,defend and
save harmlese Pine View C:ra insuirilxn from any and aN dab. and dernartds for Ions ar dKoages wtk h maybe made easinst Mrern
by resson of or corxtaciDed witty ltte c mmation of said remairra as d m:Md,wfwdw stxh dolma or dwmnds are or are ro M"y
�l 0�
�) Carleton FH
%P7T } �4
{Address}
Glens Falls NY
Ac L
{ tum and Address of Relative or lagai Representative)
Signed on tfas date:
Disposition of Cremated Remains
I hereby direct Pine View Crernatarlwn to dispose of the cremated remains as foibws:
MSH to
Odter arrangements-Pleeae spoor.
if pulverization of cremated remains Is requested,check here XX
Revision:January 1,2006