Conklin, David (7"o t4N OF QUEEVBUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name ��. i,c,� KID - Case# ,!
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Date Of Cremation ; 3o /b
Time Cremation Started _ iS �h1
Time Cremation Completed 3-, a6
Type of Container 1= ( 1.���` Of S
Remarks
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Town of Queensbury
Pine Yew 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 authorizes Pine View Crematorium,In accordance with and subject to its Rules and Regulations to
cremate the remains of:
David Robert Conklin M
(Name) (Sax)
14 Queensbury NY 12804-
(street)0 5/2 3/2 0 0 6 (City) ( ) (Zip Cam)
who died on day 2Q_.__
The Stanton Nursing & Queensbury NY
at
(piece) (Add"ess)
Name and address of nearest NAV relative or name of person audxxtdng cremation:
Colleen M. Conklin 14 Stonehurst Dr.
(Name) (Address)
Relationship to the deceSeed Wife
Name ofFurcn*Home Carleton Funeral Home, Inc. T_
IMPORTANT:
I repomm that to the best of my lov*fedge,the deceased(has)or(has no)pacernalcer,dsftMMm or any other battery operated
device in his or her body. (Cirde One)
I certify that I have full power and SUeMrfttbn to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,tot any personal possessions he"either been removed or may be destroyed,and agree to protect,deibnd and
save harmless Pina View Crematorium born any and all dakns and demands for iris or damages which may be made against them
by MOODri of or connected with the of sold remains as directed,whether such claims or demands or are nat wholly
pdtrtd false or froudular it.
JAI
(Signaturb and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as follows:
MON to
Other arrangements-Please specify:
if pulvertzation of cremated remains Is requested,check he- XX
Revision:January 1,2006