LeMaire, Royal TOWN OF QUEENSBURY
Pine Virtu Cemetery and Crenin tort wn
27 Qirnker Rond, Queenshisry, NY. 12804.5902
(518) 745.4476 (518) 745.4477
h(cP.//www.queensbury net
Funeral Director: 'Qr—C1A q
Name of Deceased: p I c, j fr
Case Number: 3 L)
Date of Cremation:
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Time Cremation Started:
Time Cremation Completed:
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Remarks:
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Home of Naturnl Benuty ,.. A Good Plnie to Live '"
• TOWN OF QUEENSDURY /
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12004
Plione(51e)Crematorium 7454477(if no answer)
Cemetery 74544.76
AUTHORIZATION TO CREMATE
The undersigned requests and authorizes Pine View Crematorium, in accordance wily and subjecl
to its Rules and Regulations to cremate the remains of:
Royal J. Lemaire Male
(NAME) (SEX)
192 Veterans Road Ticonderoga, New York 12.883
(STREW (CITY) (STATE) (ZIP CODE)
who died on 23rd day of March 05
20
at Fletcher Allen Health Care, Burlington, Vermont
(PLACE) (ADDRESS)
Name and address of nearest living relative or name of person auUjorizing cremation:
Dawn Narbon 9 Weston Drive, Clifton Park, New York 12065
Relationship to deceased Step-daughter
Name of Funeral Home Wilcox & Regan funeral home, 11 Algonkin St.
Ticonderoga, New York
IMPORTANT
represent that to the best of my knowledge, the deceased IMs or haiffl pacemaker in Iris or ber
body. (CIRCLE ONE)
1 certify that I have the full power and authorization to arrange for the cremation of llie remains and
to direct the disposition of the cremated remains, that any personal possessions have either been
removed or may be destroyedi and agree to protect defend and save harmless Pine View
malorium from any and all cakns 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 or are not wholly groundless, false or fraudulent.
(WITNESS) (ADDRESS)
(SIGNATURE OF RELATIVE OR LEGAL REP.AND ADDRESS)
Signed on this date: