McCauliffe, Lindy OF QUEEN,5BUr�y
PINE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSBURY, NEW YORK 12804
(518) 745-4476 (518) 745-4477
i Funeral Director_ C rye ,h
Name_ L � - I�c���� � -
Case# S"3 C)
Date Of Cremation L( - G
Time Cremation Started
Time Cremation Completed
Type of Container Cfri �s�:. t" Cr,i ,rc9
Remarks
a
rmm of Queensi~ifrry
Pine View Cemetery and Crematorium
21 Quakes Road, Queensbury,New York, 12NM
Cemetery Office:(518)745-4476,Crematorium:(518)745-4477
Authorization to Cremate
The undersigned requests and auCiorims Pine view Crerr>atorium,in accordance with and su*d to Its Rules and Regulations to
cremate the remains of:
Mr. Lindy James McCauliffe M
5679 State Route 4Fort Ann NY 12827-
(Street) 11/3 0/2 0 0 6 (CRY) (Stale) (zip Code)
who died on day of 20�
Resi ence Fort Ann 'STY
at
(I�lece) (Address)
Name and address of naareat Wing relative or name of person auCKwb rg cremation:
Mrs. Antonette Breault 14 Broadview Terrace Apt. 4
(Name) (Address)
Reiafiorw o to iris deceased Daughter
Name ofFuneraf Hon ne Carleton Funeral Home, Inc.
IMPORTANT:
I represent that to the Kest of my Iarowledge.fie deceased(haa)or(has no)paoeme W.dafibrO r!a or any archer balwy operated
device in his or her body. (Circle One)
I ear*that I have dal power and aUffKW ztion to an W for the aremeticn of fhe rernaft and to drect the dspoettion of the
crerneted remains,ttret any personal possssWns have either bean removed or may be deshoyed,and agree to prolect,delbnd and
save twmiess Pine View Cremetimium from any and aN cbk. and derrrerlds for ices ar damoM wtich met be made apeinei vmm
by reason of or corxietled with the aurae n of said ranw0ns es fiecied.whWw such ciairne or dwonds are or are not ate ft
grottritNear,false or frellduisnt.
r - - 01- -G 8
(Wibiess) (Addeas)
(Signattse and of Relative or t.egal Representative)
signed on ltie dale: �,_ 9—O b(o
DISpos#ion of Cremated Ronam
I hereby Bred Pine View CremeRorium to dispose of fha cremated remains as follows:
MeN to
Other erranpennn"-Please spec fy:
If Pulver Zation of cremated remain Is requested,check here XX
Revision:January 1,2006