Gordon, Maxine L07 VN OF QUEENl..L-�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ �r- -fc
Name N(c-, o �';,�-��
Case# ��a
Date Of Cremation 7.-t2-- Ct-
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Time Cremation Started '1. 1s A M
Time Cremation Completed '. �a 4M
Type of Container �ti��. �unf-� - ( 5 (A )(-.
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quakes Road, Queensbury, New York, 12&9
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and audxAms Pine View Crematorium,in accordance with and subject to its Rules acid Regulations to
cremate the remains of.
Maxine Marie (Jones) Gordon F
(Name) (Sax)
41 William Street Hudson Falls NY 12839-
law") (CRY) (State) (Zip Code)
who died on 9 t h day of July 20 06
Glens Falls Hospitai G ens Faiis --7Y
at
(Piece) (Address)
Name and address of neeroat Nrirwg relative or name of person arrtlhoriano cremation:
Darlene Gordon 399 Buttermilk Falls Rd, Ft Ann, NY
(Name) (Address)
Reletlonshp to the demesed Daughter
Name of Funeral Home Carleton Funeral Home, Inc. T^
IMPORTANT:
I represent that to the best of my Imowledge,the deceased(has)or(has no)pacemeW,delbNlam or any other battery operated
device in his or her body. (Cede One)
I aer ft that t have full power and eufftoriration to arratW for the cremation of the remains and to direct the disposition of the
cremated ramabts,that any personal pions have either been removed or may be destroyed,end ag me to protect,defend and
save harmless Pine View Cretrotor lum from any and all dab, and demands for loss or damages which may be made aonind them
by meson of or ouxtnacled wb cremation of said remains as directed,wheffm such chums or dernands we or are not wholly
orq „false or
l� vVt Carleton Funeral Home, Inc.
���2 (VYRrheas} (Address)
399 Buttermilk Falls Rd, Ft Ann, NY
(Siortawre and Address of Relative or Leo Representative)
Signed on 1his date: 7 / to Z 0 r '
Disposition of Cremated Remains
I hereby direct Pine View Crematorium to dispose of to crerneted remains as tk-s:
mall to
Ocher arrertgements-Please specify:
If pulverization of cremated remains Is requested,dheKic hens XX
Revision:January 1,2006