Perry, Mary '7"oVN OF QUEEN B2.1
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PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
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late Of Cremation
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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 uKdersigned requests and auftwizes Pine View CreauKodum,in aoowdance with and sub]ert to its Rules and Regulations to
comets the remains of
Mary Ann (Hilla) Perry F
(Nam) _ _—V (SOX)
Eden Park Nursing Rdmes Falls NY 12801-
(Streel) 06/06/2006 (City) ( ) (Zip Code)
who died on day of 20
at EDEN PARK HEALTH CARE CENTER Glens Falls
( ) ( )
Nome and address of nearest WAV relative or name of person aulhorbft cremation:
Mr. Jack Molema 6611 River Road
(Name) (Address)
rtelatiornship to the deoeesed
Son
Name ofFurneralHome Carleton Funeral Home, Inc. T�
IMPORTANT:
t repreaernt that to the best of my ionowledge,the deceased(heo)or no or eny other bottay opmeted
device in his or her body. (Circle Ora)
I certify that I have ho power and authorization to arrarw for the cremation of the remains and to direct the dl9poeMion of the
cremated remains,**any peraornai possessions have either been re roved or may be destroyed,end agree to protect,defend and
am harmless Pine View Cretnetalum Nam any and all china and demands for ions or demagee which may be made sp hid them
try r+eesort of cr cortne w#h ire cite�Mf said remains as directed,wtelhe►such claims or demands ere or are riot wholly
false ule .
{Address}
(SignaWre and of/R'ela m or Leo Rcpres re)
Sided on Ws date:
Disposition of Cremated Remains
I hereby direct Pie View Cremelorrum to dispose of the cremated retrnetns as foeows:
Man to
Other scrartpemernts-PNOW spedfy:
if puivervation of cremated remains Is rieques%4 check here XX
Revision:Jerruary 1,2006