Armstrong, Jean L OF UEE
PLNE VIEW CEMETERY AND CREMATORIUM
QUAKER ROAD, QUEENSHURY NEW YORK 12804
(518) 745.4-476 (518) 745•-4477
_ Funeral Director I
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Dace Of Cremation
T .me Cremation Started
Time Cremation Completed t(o Ppf
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Remarks
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Town of Queensbury
Pine View Cemetery and Crematorium
21 Quaker Road, Queensbury,New York, 12804
Cemetery Office: (518)745-4476,Crematorium: (518)7454477
Authorization to Cremate
The urxlarsigned requests and authorbm Pine View Crematorium,in acoordence with and subject to Its Rules and Regulations to
cremate the remake of..
Jean Armstrong F
(Name) (sex)
176 Dubes o, 14 14c-4- cls }�- KA IoZ�-7
(street)01/0 7/2 0 0 7 (City) (State) (Zip Code)
who died on dal►of 20---
Glens Falls Hospital Glens Falls NY
at
TWO (ems)
Name and address of nearest Rvins rehWw or name of parson a►ditort"cremation:
Mrs. Judy Sullivan 140 Dube Road
(Name) (Address)
Relatkwv*ip to ft detteesad Daughter
Name of Funeral Hor, Carleton Funeral Home, Inc. T_
IMPORTANT:
1 represent that to the Crest of my larowledga,the daceeaed(has) (has no) maker,def ibrpiafor or any other betwy operated
device in his or her body. (Circle One)
I cw*that I have fug power and augn t moon to emerge for the crerrallon of the remahts and to direct the dlsposilion of the
cremated remains,that any personal possessions hove either bash removed or may be deshoyed,and aprae to protect,defend and
save httarrtlBss Pine View Crematorium tram any and all claims and dernwtds for loss or dw ages which may be made apakrst I m,
by n>Ieson of or connected with the cnw m m of said remahs as drecled.Whalher srxh cialtrrs or IsareoraFenotw0holly
protxxtlaa5,false Or fraud �f�[ � Q
O(Yygrtees) �\
X ($1gna Address of Retative a t epaf Representative}
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Signed on this dote:
Disposition of Cremated RemaWe
I hereby direct Pk*View Crematorium to dispose of the cxemeted remains as Wows:
Mall to
Other amanpamerrts-Please specify:
if puwerWRion of cremated remains Is requested,check hem XX
Revision:Jwujwy 1,2006