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Willette, Adeline '7"174/N OF QUEEVBUr�y PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSBURY, NEW YORK 12804 (518) 745-4476 (518) 745-4477 Funeral Director Name � �� W ; ��i, � C Case# 351 Date Of Cremation - - c; Time Cremation Started Time Cremation Completed 5 .2t, alb Type of Container ClvTk (; rat � (� ., �� 57 �AS� Remarks = 1G 1�N1 Town of©ueensbury Pine View Cemetery and Cremat+wium 21 Quaker Road,Queensbury,New York, 12804 Cemetery Office.(518)745-4476,Crematorium;(518)745-4477 Auft ization to Cremate The wxImsored requests and ai*"tzes Pais View Crematorkt,in accop&w%oe with and w4ect to its Rulers and Roostions to aerate the rely"of Adeline Mary (Scarselletta)(d; f F (blame) (Sex) Indian River Granville NY 12832- (Street)0 8/0 6/2 0 0 6 (City) ( ) (�Code) who died on day of 20_ INDIAN RIVER REHAB & Granville NY at (Place) (Address) Name and address of ncerot living reap M or name of person 0*"tdnp eramat m Mr. Gerald Willette 2055 Norman Way (Name) (Address) Rekdkvn►ip to the deoea9ad S o n Name ofFumadHome Carleton Funeral Home, Inc. �! LUPORTANT. 1 represent that to to best of my Imowiedge,the deoeais ed{has tx{has no maker,c eftillala or any otter betiary operated device at his or her body. (Cade Orm) 1 oeriiry that l have U power and author ion to arrarW W the ammo m or the resets and to direct the dot of the cnwneted remaars,that arty persanal PossessWm hove either been removed or may be destroyed and agree to protect,deflwW and save harmless Pine View Cremakmiu n from any and all dakm and demmids for toss or damages which may be made against them by n e5on of or corrocled with On crematiOR of said retrmm as dir+etted,whew such dalms or demarxis we or are not wholly urour4m.use or / (Address) !� (Som and Address of Relative or Legal Rep vssrAslive) Signed on this data: OisposAion of Cremated Remains I hereby dxW Pate View C remaWrhntt m dispose of the cremated remaars e5 MOWS: Man to Other arrangements-Please specKy. if pWve mM=of cremated remem 13 requested,Break here XX Revision:Jfl w 1,2006