Corlew, Marjorye L 1"7+N OF QUEEN,5BU-r�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745.-4477
Funeral Director C'C�
Name Or e�
Case#
Date Of Cremation
Time Cremation Started p0
Time Cremation Completed 2 L ® P,
Type of Container b o o fd
Remarks �--------
is PA
2 : p,M
2-
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, VWX
Cemetery Office: (518)745-4476,Crematorium: (518)745-4477
Authorization to Cremate
The undersigned requests and authofaes Dine View Crematorium,in a000rdanoe with and subject to its Rules and Regulations to
cremate the remains&
Marjorye Elizabeth Corlew F
(Name) (-CWW)
16 Jackson Ave. South Glens Falls NY 12803-
(Street) (City) (State) (zip Code)
who died on 9th daYof December 20 06
16 Jackson Ave South Glens Falls NY
at
(Place) (Address)
Nome and address of neen'et living relative or name of person autfwM"cremation:
Mrs. Debbe Dorvee 212 Hatchery Rd, Gansevoort, NY
(Name) (Address)
Relatkxv;hip to Mae decreased Daughter
Name of Funeral Home Carleton Funeral Home, Inc.
IMPORTANT:
t represent that to the best of my lamwiedpe,the deoeased(has) no maker,deftft or or any other banary operated
device in his or her body. (Ckda One)
I cotiy that t have ful power and suit orization W arrange for the cremation of the remains and to direct the disposition of the
cremated remains,Mast any personal possessions he"either bash removed or may be dedmyed,and agree to protect,defend and
save harmless Nine View Cren*torium from any and aN claims and fin P rde for km or damages whirl►maybe made ap kid thorn
of or oortrredsd with the aemedon of said remains as directed,wtielher such dairis or dariends are or are not wholly
fallge or fraudtAertt.
��-- Carleton Funeral Home, Inc.
(witness) (Address)
212 Hatchery Rd, Gansevoort, NY
(Signature and Address of Relative or LOW Representative)
Signed on this date:
Disposition of Cremated Remains
I hereby direct Pie View Crematorium to dispose of the cremated remains as idk-$;
Map to
Other arrenpemerrts-PMMW spedty:
If pulverization of cremated remains Is nxwested,check hens XX
Revision:January t,2006