DuFore, Jane 'OWN OF QUEEN,5BU,9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director
Name Case#
Date Of Cremation
Time Cremation Started
Time Cremation Completed >: oo
Type of Container otL C" -CC S CAS_
Remarks
0 2v
06
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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 authorizes Pine View Crematorium.In accordance with and subject to Its Rules and Regulations to
cremate the remains of:
Jane (Flood) DuFore F
(Name) _ (sex)
Apt. 31, Hudson Falls NY 12839-
(Stree!)0 7/17/2 0 0 6 (CRY) ( ) (Zip
Code)
who died on day of 20�
Albany Medical Center Albany NY
at
(Place) ( )
Name and address of new Nvirg roWNw or nnww of pennon auVwxt*g cremation:
Mr. Thomas DuFore 294 Gansevoort Road
(Name) (Address)
Rekdkw Op to the deaeasad S o n
Name of Funeral Home Carleton Funeral Home, Inc. T�
IMPORTANT:
!represent that to the bast of my knorrtedge,the deceased(has)or(has no)pacemaker,deftillaloor or any other battery operated
device in his or her body_ (Ckde One)
I cer"that t have full power and authorization to arrargs for the cremakm of the remains and to direct the dlspoai w of the
cremeted remains,*w4 any perso poseeselona have either been removed or maybe destroyed,end agree to protect,defend and
save harmless Pine View Crematorium from any and all claims and dar,m for loss or damages wtk h maybe made against them
by reason of or connec led with the cremation of said remains as diftled,whedw such chime or dernands are ar are nat wholly
orwiidleR3.. or frelldWAnt. e
3� C-r�fE C�Cres �d. "�dso,� ells Ny to.93(
I&N�(ww,eas (Adds)
(Signature and Address of Relative or Legal Representative)
Signed on this dote:
Disposition of Cremated Remains
I hereby direct Pine View Cremstorkim to dispose of the cremated Fsms ns as Wows:
MON to
Other arrangements-Please specify:
if pulvertEation of cremated remains Is requested,dheck hem XX
Revision:January 1,2006