Dunham, Barbara TOrkIN OF
QU EENsSB`ZI
PINE VIEW CEMETERY 1'�/
QUAKER ROAD AND CREMATORIUM
QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
Funeral Director CC1 ( . �
Name ar �u,hcK, -
"r�' Case#
Date Of Cremation - T
Time Cremation Started 30 �
Time Cremation Completed L"
'u
Type of Container
Remarks L''a'" '� �sr C
�{Sn
ft
All-
(�,L fie k
bN
Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12&9
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The usmersigned requests and authorizes Pere View Crematorium,In ecaordenoe with end subject to its Rules and Regulations to
cremate the remains oF.
Barbara Dunham F
(Nome) (S")
6 Edgewood Queensbury NY 12804-
(Street)11/0 5/2 0 0 6 (City) (state) (Zip Cade)
who died on day of 20�
EDEN PARK HEALTH CARE Glens Falls NY
at
(Place) (Address)
Neese and address of nearest living relative or name of person arrthodit cremations:
Warren Dunham 6 Edgewood Drive
(Name) (Address)
Rebtionship to the deceased Husband
Name ofFurxm*Ham Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the hest of my lasowledge,the decessed(has)or(has no)psoar .re ker,detfb Malor or any other battery operated
device in his or her body. (Cicis One)
I CW*that t have kA power and auft rization to arrange for the cremation of the remains and to direct the disposition of the
cremated remains,!het arty persoi a!possessions have ether been removed or may be destroyed,and agree to protect,defend and
am harmless Pine View Crematorium from any and aN ciah. and demands for foal or damages v*k b may be mods apsi nst them
by reason of or connected with the cremation of said remains as dYected,whWw such chime or demands are or are not wholly
false or freudulertt. Of
J (Witness) (Addam)
(Signature
� iatve am Address of Re or I sW Representative)
Signed on this dote: ( d V. (y R 2,6 O(.
Disposition of Cramated Remains
I hereby direct Pine View Crematorium to dispose of the cremated remains as stows:
MON to
Other errervement s-Pbase spew.
if pulvervation of cremated remains Is requested,diet*here XX
Revision:January 1,2006