LaPlanche, Frank A
TOWN OF QUEENSBURY
Pine Virtu Cemetery nnrl Cremn tort um
21 Quaker Road, Queenshury, NY. 12804.5902
(518) 745•4476 (518) 745-4477
http //w%v\v queensbury net
Funeral Director: r,
Name of Deceased: EP, 41'1) « � ?a Pilf1
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Case Number: �7 r6
Date of Cremation: `3 — 1 2v o j
Retort: ZF F—
Time Cremation Started:
Time Cremation Completed:
Type of Container: G{A��c7 Pid P'Q e'�k�x� ivt, a
Remarks:
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Hone of Nnturnl Benuty . A Good Place to Live
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:
Frank LaPlanche Male
(Name) (Sex)
Mud Pond Road Queensbury,NY 12804-
(Street) (City) (State) (Zip Code)
who died on 24th day of February 2005
at 25 Mudpond Road Queensbury,NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Terry LaPlanche P.O. Box 3491 Glens Falls, NY
(Name) (Address)
Relationship to the deceased Brother
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or as no.
pacemaker in Epr her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cremation
of the remains and to direct the disposition of the cremated remains, that any
personal possessions have either been removed or may be destroyed, and agree
to protect, defend and save harmless Pine View Crematorium from any and all
claims and demands for loss or damages which may be made against them
by reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
i
�- 68 Main Street, Hudson Falls, NY 12839
` (Witness) (Address)
Glens Falls, NY 12801
( ignatu f elative or Legal Rep. and Address)
Signed on this date: