LaTulippe, Shirley (-r0 WN OF QUEEVBU9�
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name 5L)rIt, Lg ( J o Case# qy`'1
Date Of Cremation
Time Cremation Started 11 VC-) A M
Time Cremation Completed 1 . ')V Pd
Type of Container CgC4 �u°I r y/ wood :('r5„y"0-
Remarks
r%01In 11; io A M . 11 50
Ri
1 � so?N1
TOWN OF QUEENSBURY o�
PINE VIEW CEMETERY I
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:
Shirley Carrie (Sherman) LaTulippe Female ..
(Name) (Sex)
4E Earl Towers St. Paul's Drive Hudson Falls,NY 12839
(Street) (City) (State) (Zip Code)
who died on 2 day of October
at Residence , *1
(Place) (Address)
Name and address of nearest living relative or name of person authorqpg cremations:
Mrs. Gloria Fish Reynolds Road Fort Edward,NY
(Name) (Address)
Relationship to the deceased Sister
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge, the deceased has or a no
pacemaker in his or 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 destro . ,,an 4,Q*
to protect, defend and save harmless Pine View Crematorium froriy and all _.
claims and demands for loss or damages which may be Ode ac nsl►the ,,
d with the cremation of said remains as direct4ed, -
, fatsff
by reason of or connected �
whether such claims or demands are not wholly groundle or fraudulent.
68 Main Street, Hudson. Fal'J 414NY 12839
(Witness) (Address) ; . IML" .
6,
(Signature of Relative or Legal 146p. and Address) �' °,`
Signed on this date: 0 � � `