Wells, Lucy L O Y+N OF QUEEN,5BU!)�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director_ �lefa�.
Name Luc�, Qf (�S Case# L13b
Date Of Cremation in 3 GL
r
Time Cremation Started
Time Cremation Completed
lI_
Type of Container LASE
Remarks
i
q L
Town of Queensbury
Pine View Cemetery and Crematzx um
21 Quaker Road,Queensbury,New York, 12804
Cemetery Of w.(518)745-4476,Crematorium:(518)745A477
Authorization to Cremate
The tsdersowd requests and auftwizes Pine View Crematorium,in scoordarhoe with and subjeol to fts Rules end Reps ftbm to
cremate the Mau"of:
Lucy Edna (Fenton) Wells F
(Name) (SO4
Pleasant Valley SNF Argyle NY 12809-
(S'treet) (City) (State) (ZIP code)
vAo died on 30th dayofSeptember 20 06
at
PLEASANT VALLEY NURSING FAC. Argyle NY
(Place) (Address)
Name and address of nearest oft reWfive or nacre of parson au#wrb*V crartatim:
Mrs. Retha Rempher 110 County Route 41
(Name) (Address)
Refatior>shfp to the deoeaead
Daughter
Name ofFmv at Home Carleton Funeral Home, Inc. T_
NMPORTANT:
1 represent that to to best of my bnwiedge,the deceased(hers)or(has no)peoamalter,deftil aW or any other hAwy operated
device in his or her body. (fide One)
I that I have ftA power and auffwr rmtim to orange for the cremation or the rentakis and to direct the disposition of the
creavaed remains,that any pe+awai possesshxes have either been removed or may be de Muyed,and aaee to prolect,defend and
sang harmless Pine View Cramelorlum uom arty and at claims and demands for Tars or damages which rtaeiyy be made agairm than
byr of or connected with the cremation of said remebts as( eaed,whether such cairns or demands wear are not w h*
�tt(JOC-L—Atdse
^ Carleton Funeral Home, Inc.
(Address)
` 110 Cty Rte 41, Hudson Falls, NY 12893
( and Address of Relative or Legal Rep aserMalive)
Signed on Utia date: 9/ 3'Z V;
Orion of Cremated Remains
I hsrmby drec l pM9 View Crematorium m dispose of the cremated remairy as tk-%:
Med to
Other arrangements-Please specify:
ff pulverW ion of cremated rswK*as is requested,chm*hers XX
Revisiorh:Janney 1,2W6