Carlson, Lethea rrO Y N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name I_e-r14eA C,-AI- -5dN( Case# 1 L
Date Of Cremation
Time Cremation Started
Time Cremation Completed 1d
Type of Container
Remarks
4-
Ly
�C)a:61
03/27/2006 11:42 404-609-6645 PIED PATHOLOGY PAGE 01/01
93/27/2006 10;01 78GG922 AGINGS HELPING HANDS F'ALf- 02
Town of Queensbury
Pine View Cefnetery and Crematorium
21 Quaker Road,Queensbury,New York 12804
Cemetery Office:618-745-4476,t;rer*torium:513-745-4477
Authorization to Cremate
The LwowsVtatt fequeet'e end antwraes Pkw vww emmaoortum,M ocwrow—vm art eu4)eet to ib Rulm 04 Repul Www to
owns*the remains ok
Mrs. 2adva Carltm Ptanale
(NOM) (W
3470 VT RM. 34 N. Poultmy, Vermont 05764
(street) (CMy) (Staoa) (Zip 00*
who df frd on 25 th deny of March 20,L
at sh*iand Regionai bWical oent+er- Rutland, VT
( ) 04*0 s)
Name sm address of rteerem Ww q rain"or nerve Of person autrrertrinp aernaeon:
Mr. Glen Carlsm 3412 AlealsA= Circle N.B. Atlanta,GA.
(Noma) ire) 30326
RetwVa,%l up to ft rtaoaaaad $oil.
Nerve of FurWISl dome Roberts-Aubi n F"ral HOM
IMPORTANT;
11 that to the best a my w*wledpa,the deiaveold it") np Aker,daflb,lAaeer or eery cellar henacY operated
dance in h Is or her body. (Clyde One)
100y that I have*A flower orb W"Xt c%bn 14 aeanpa br ft aemnttan d IrN(04 k*end tp fi W"tAspoN00rt of the
cremated rem Ins,that any w panquiaw have emter been fanovW or rrwy be datttroyed,end epras to WAG" dOft end
save hanrrle99 Pine Vlaw CrentaMrtum f=any and aM dekm and Caelanda idr toss a*nOM WVA may be made epatnst ttrem
by reeeon of or eonneOad vvM me eremetton of said rsm irw sa ditecwd,wharw Koh dalms or dwnwws a*or arc not wh* ,17
ffx � 6
� fiA � 7 4/ + ` 903 r/
x (siDt►a=04 AdMW of fiela"er 6e0el PAPM®e(talnle)
slpned on Oft deer,
cispaeNkm of crentaw Remalrta
hereby dhea Phe View Cremelvel m to dF9pose of uta oNnaaed tematrn a$10110wx
Mai,to N/A
other wmrVeffw ts.Pbase speatr:
it"e►tzatw of rxarnatad remains is Ya A t d,creak here
RevWm:July 7,2004