Conklin, David (2) OF QUEEVBUPy
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name �,� � c� �W.� ��
Case#
Date Of Cremation /3o'
Time Cremation Started
Time Cremation Completed C.6 �'',
Type of Container ( •,r� �aK'C� j �� 1.;� � 5
Remarks
.;, ail
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury, New York, 12804
Cemetery Office: (518)745-4476, Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and aulhoriies Pine View Crematorium,in accordance with and subject to its Rules and Regulations to
cremate the remains&..
David Robert Conklin M
(Name) -- (Sex)
14 Queensbury NY 12804-
(S"W)05/23/2006 (City) (state) (Zips)
who died on day of 20__
The Stanton Nursing & Queensbury NY
at
(fie) (Address)
Name and address of nearest living relative or name of person auCrormng cremation:
Colleen M. Conklin 14 Stonehurst Dr.
(Name) (Address)
Relationship ID the deceased Wife
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
1 represent that to the best of my i xwAedge,the deceased(has)or(has no)peoernalter,delibrillm or any o0w battery operated
device in his or her body. (Circle One)
certify that I have full power and atrt wrt mtion to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,*het any personal possessions trove either bean removed or may be destroyed,and agree to protect,deibnd and
save harmless Ph*View Crematorium ttom any and all clai ns and der wKb tar ions or damages wtich may be mede against them
by rGAMon of or connected with the of said remains as directed,whellier such daims or demands or are not wholly
gr i false or frartidulant.
(WRr>ass (Address)
mac.
(Signatur6 and Address of Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remake as follows:
Mad to
Other arrargements-Please epedfy:
if pulverization of cremated remains Is requested,check here XX
Revision:January 1,2006