French, Richard OF QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed
Type of Container
Remarks
ell
;�� 7
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12&9
Cemetery Office:(518)7454476,Crematorium:(518)745-4477
Authorization to Cremate
The mderaigrmd requests and autiho tm Pine view Crernatoriurn,In accordance with and subjW to its Rules and Reputations to
cremate the remalrs of.
Richard French M
( ) (SOX)
9 Flushing South Glens F�oLt(S. NY 12803-
(Street)0 6/0 2/2 0 0 6 (CRY) (�) (ZIP Cade)who died on day d 20�
Residence South Glens Fc:, tts NY
at
(niece) (Address)
Name and address of. living relative or name d person autxxt"cremation:
Rita French 9 Flushing Avenue
(Name) (Address)
Relatirmi0otothedeoeaead Mother
Name of Funwat Home Carleton Funeral Home, Inc. T!
IMPORTANT:
I represent that to the best of my krawledpe,dw deceased(has)or(has no)pacemaker,det b ilia r or any o0w battery operated
device in his or her body_ (Circle One)
I certify that I have fat power and suthartration to arrarW for the crematian of the remains and to direct the disposition of the
cremated remeims,Meet any persana!possessions have either been removed or may be destroyed,and agree to protect,delbnd and
save 010'. ss Pine Yew Crematorium from fr
arty and ap daimis and demands for ions or damages which may be made against Maerur
by reason of or connected with the ' of said remains as directed,wtwow such claims or demands are or not wholly
wwww9emse,or fraudulent.
( Z�A,�-
( of or L R �U���!/✓�� �v� u
3iWmd on this date:
Disposition of Cremated Remains
I hereby dheci Pine View Crematorium to dispose of the cremated remains as ldlows:
Man to
Other arrenpemer"-Phan specify: _
if puivertzation of cremated remains is requested,check here XX
Revision:January 1,2006