Sexton, Hollis ��2v OF QUEEN,5BUTr
WE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QLTEENSgijRy, NEW YORK 12804
(518) 745-4476 (518) 745'-4477
Funeral Director Cc;(`('tfeh
.Fame �I��� s SQ ion
C a s e# 'j 71
Date Of Cremation
Time Cremation Started
Time Ctemation Completed <f6. 1�M
TYPe of Container
1004)c>
Remarks
----------------
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5 7q
Town of Queensbury
Pine Yew Cemetery and Crematorium
21 Quakes Road, Queensbury, New York, 12804
Cemetery Office:(518)745-4476, Crematorium: (518)745- 477
Authorization to Cremate
The undersigned requests and auftwizes Pkte view CrernikAum,in accordance with and subject to its Rules and Regulations to
cremate the remains of:
Hollis Stewart Sexton M
(Name) (sex)
440 Saratoga Moreau NY
(Sir")12/2 2/2 0 0 6 (City) ( ) (zip Code)
who died on day of 20__
Residence Moreau NY
at
(Place) ( )
Name and address of nearest Nvirts relative or name of person aulhorb"crematioon:
Mrs. Louise Sexton 440 Saratoga Road
(Name) (Address)
Relationship to the deoeeaed Wife
NameofFuneralMoma Carleton Funeral Home, Inc. TR
IMPORTANT:
I mpreem that;to die best of my Www4edga,the deceesed(has) noemalaer,deflbdlls or or arty other battery operated
device in his or her body. (Circle one)
I certilly that t have ful power and authorization to arrange for the cremation of the►emahts and to direct the disposition of the
cremated remains,that arty personal possessions have eNltar boar removed or may be destroyed,and apse to protect,deibnd and
save harmless Pine View Ctecrrstorium from any and aN dsirrre and dernarrds for toss ar damages vttich mey be made soWnat them
by Lesson of or commued with fha ami a ft of sold remairte as directed,wtw0w such d ns or dw wnds are or are not Wv*
p our diess,false or fraud
a ry'ka.
(Witness) (Ads)
X ,�•- ,.:� L� l 5'9 r —V-fF?7
(Signature and Address of Relative or legal Repreaeritative)
Signed on this date:
Disposition of Crerntated Remains
I hereby direct Pine Vlaw Cr amok whim to dispose of the cremated remains as foNows:
Mom to
Other errengamtmi s-Pbaee specify:
If puiverfrzafioa of cremated remains Is requesk4 check here XX
Revision:January 1,2006