Patterson, George norm/N of QUEEVBU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director Carl
Name
—_ /7
TS� A60rSoti Cased AC)
Date 0f Cremation S /4 /GL
Time Cremation Started -]'_(5 4tj
Time Cremation Completed $; U�
Tvpe of Container Ca
w �vo c� t4.0-fa
Remarks
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 mdersignad requests and&&wrkws Pine View Cretrtatorium,in accordance with and subject to its Rules and Regulations to
cremate the remains of.
George William Patterson M
(Name) (S")
91 Briwood Queensbury NY 12804-
(Street)0 5/0 2/2 0 0 6 (C" (fie) (zip Code)
who died on day of 20_
Albany Medical Center Albany NY
at
(Place) (Address)
Name and address of rteeraat living m ftvm or named person auatorb*V cremation:
Miss Janet Harding 91 Briwood Circle
(Name) (Address)
Relatiol IMhlp to the deceased Mother
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the best of my knowledge,the deceased(has) no) maiden.deNbrlNator or any other battery operated
device in his or her body. (Clda One)
I certify that I have f A power and subtartration to arrange for ttre crew SdOn of the remains and to direct the disposition of the
cremated remains,that arry pe"Onerf possessions have either been ren ved or may be deedoyed,and agree to protect,defend and
save hanrrless Pima View Crematorium from any and aN c1sin and demands for loss or dernagss which may be made apart them
by reason of or connected with the serration of said remakts as directed,wheMe►such daims or demands we or are not wholy
groundless,false or fraud
7
(Address)
(Signature and Address Relative or Legal Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains SS bNows:
MaN to
Other em9ngaments-Please spedfy:
If puiverboion of cremated remains Is requested,check here XX
Revision:January 1,2006