Loading...
Smith, Frederick (-rn%N OF QUEEVBW� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 h_ II'',, Funeral Director Cj41Z1-��J Name ��LCJ G 1 t NL 1 Case# Date Of Cremation � -- L Z,OC 62 Time Cremation Started 3 © ✓� Time Cremation Completed Type of Container ���}�-�U)C1�/ (; �(,� 2'(y Remarks C 1264,Lt) Ft)tz - Rom' -47 10 1 I 3`S ;�-► Town of Queensiwry Pine View Cemetery and Crematorium 21 Quaker Road,Queensbury,New York, 12&K Cemetery Office:(518)745-4476, Crematorium:(518)745-4477 Authorization to Cremate The uncimsVied requests and auQ"tass Pains View Crematorium,in accordance with and subject to its Rules and Regulations to cremate the remains of.- Frederick William Smith M 8C Oakwood Hudson Falls NY 12839- ( )O l/2 8/2 0 0 6 (CRY) (State) (ZIP Co&) who died on day of 20� Glens Falls Hospital Glens Falls NY at ( ) (Address) Nerve and address of nearest Wing relative or name of person aulhoroirrg aerrraliorr: Beverly Smith 8C Oakwood Drive hlu�s�n Fa//g�t�i.�• "me) (Address) Reladrxghip tb the deOeased W i f e Name of Funeral tcm Carleton Funeral Home, Inc. T� IMPORTANT: I represert Out tO the best dray Imowledge.the deceeaed(has)or no)plpemeloer.defibialor or any other batty operated device in his or her body_ (Cards One) certiy that I have fu1 power and atr Knmtion to arrange for the cremation of the remains and to direct the disposition of the cremated remains,that any personal possessions he"either been re n wed or mey be destroyed,and apee to prolect,defend and save harmiess Pine View Crematorium bon any and al dai ns and demands for iris or damages vA*h maybe made apairffit them by reason of or connected ted with the cremation of said remains as dread,whether such chins or demands are or are riot wtroiiy faise or freuriu^lerl�' // DD,� may{ /� �,• J�J,� �.( (VYitrleas} {Address} X and Of Rela<lae L XWI Repr ssenMve) Signed on Oft date: -Tan z g2 a-on 49 Disposition of Cremated Remains I hereby direct Prue View cremeioduin to dispose of the aanated rerrraks as foeorvs: MaN to Otrw arrangements-Please spew. If ptdveriz tion of cremated remains Is requested,c hack here XX Revision:January 1,2006