Herald, David L O Y N OF QUEEVBU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director C-,) V4`2 f C4-U p
Name � 'Z�'j��� �rL Case#
Date Of Cremation Li
Time Cremation Started 11
Time Cremation Completed
Type of Container-y-L"Fyd
Remarks '
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quakes Road,Queensbury,New York, 12804
Cemetery Office: (518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and authorises Pine View Crematorium,in accordance with and subject to Its Rules and Regulations to
cremate the remains at
David Jeffrey Herald M
190 Hulett Granville NY 12832-
( )03/28/2006 (CRY) (�) (Zip Code)
who died on day of 20—
at
(Place) (Address)
Name and address of-merest living retadve or name of person autiorbting cremation:
Jeffrey Herald 190 Hulett Road
(Name) (Address)
Relatio-ship to the deoeaead Father
Name of Funeral Home Carleton Funeral Home, Inc. T_
IMPORTANT:
t rapreew that to the best of my IahoeMedge,the deceased(has)or(has no)pa muielter,dBAbrNiuft or any other battrjry operated
device in his or her body. (Cirds One)
I certify that I have U power and eLOKw sation to arrange for the cremation of the remains and to direct the disposition of the
cremated remains.that any p F N r, al possessions have either been removed or may be destroyed,and agree to proWt.deibnd and
seve harmless Pine View Cremsiaium trom any and all claims and demands for loss at damages wtdch may be made against fhern
by afar with the cremation of sold remains as directed,wtwdw such claims or demands are or are mot wholly
7 or
r
(Address)771,Te,jito V UnA q I I
of ReKdk or Legal Represerltatin►e)
Signed on tfhis date: /9,4x act of d 0&
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Disposition of Cremated Remains
I hereby dirred Pine View Crematorium to dispose of the Cremated remains as MMM:
Mall to
Odw erntngements-Please specify: _
if pulvervation of cremated remains Is requested,check here XX
Revision:January 1,2006
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