Lancette, Richard Sr. L O OF QUEE_ 5BU9�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY NEW YORK 12804
(518) 745-4476 (518) 745.-4d77
Funeral Director of ��,�v"
Name RICurd L�,r�cF� Sr, --
Case# 9
Dace Of Cremation o — 11— �
Time Cremation Started 'T j3 M
Time Cremation Completed 56
Type of Container
Remarks
M
2 4f 6 A I7
o ' IL
TOWN OF QUEENSBURY
PINE VIEW CEMETERY
CREMATORIUM
Quaker Road, Queensbury, New York 12804
Phone (518) Crematorium 745-4477 or if no answer
Cemetery 745-4476
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:.
Richard D. Lancette, Sr. Male
(Name) (Sex)
3511 SR 196 Hartford, NY 12838
(Street) (City) (State) (Zip Code)
who died on 7th day of December, 2006
at Glens Falls Hospital, Glens Falls, NY
(Place) (Address)
Name and address of nearest living relative or name of person authorizing cremations:
Mrs. Sharron Lancette, 3511 SR Rte 196, Ft. Ann, NY 12827
(Name) (Address)
wife
Relationship to the deceased
Name of Funeral Home
IMPORTANT:
represent that to the best of my knowledge, the deceased has or has no
pacemaker in his or her body. (Circle One)
I certify that I have the full power and authorization to arrange for the cremation
of the remains and to direct the disposition of the cremated remains, that any
personal possessions have either been removed or may be destroyed, and agree
to protect, defend and save harmless Pine View Crematorium from any and all
claims and demands for loss or damages which may be made against t#lem
by reason of or connected with the cremation of said remains as directed,
whether such claims or demands are not wholly groundless, false or fraudulent.
Carleton Funeral Home, Inc.
(Witness) (Address)
2511 SR 196 Ft Ann, NY 12827
(Signature of Relative or Legal Rep. and Address.1
Dec 7, 2006
Signed on this date: