Teeter, Everett TORN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name =y R + F—F-' Case#
Date Of Cremation 3C)— Zip
Time Cremation Started V 3 45
Time Cremation Completed . `
Type of Container CvA2VA-:1 c;t- k4(4 tj
Remarks
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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 undersigned requests arnd autirort¢es Pine View Crernatorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Everett L. Teeter M
(Nam) _._ ___ (Sex)
215 Wait Road Kingsbury NY 12839
(Street) (City) (state) (Zip Code)
O
who died on 1/24/2006 day of 20—.
Residence Hudson Falls NY
at
(Place) (Address)
Name and address of nearest living relative or name of person authortaing cremation:
Ann Taylor Powers 215 Waite Road
(Name) (Address)
Friend
Relationo p to tine daoessed
Name ofFuneratHome Carleton Funeral Home, Inc. T_
IMPORTANT:
1 represent du t to the best of my bowledge,the deceased(has) nab maker.detibriNator or any other battery operated
device in his or her body. (Code One)
I certify that i have full power and suftrbation to arrange for the cremation of the remains and to direct the disposition of the
awnsted remains,that any personal possessions have either been removed or may be destroyed,and agree to protect,defend and
save harmless Pine View Cremelairtrn from any and all claims and demands for lots or damages wtirh may be made against them
by reason of or corrtecyed with the cre naft of said remi nts as directed,whether such debm or demands are or are not wholly
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ttme and Addreq§of Relative or Legal Representative)
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Signed on this date:
Disposition of Cremated Remains
1 hereby direct Phte View Crematorium to dispose of this Cremated remains as ltd"s:
Mall to
Picked up by Carleton Staff
Otiter arrangements-Please specify: -
if purlverbolon of cremated remains is requested,check here XX
Revision:January 1,2006