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Fellman, Thomas
l O 3V OFQUEE9�5Dur7� PINE VIEW CEMETERY AND CREMATORIUM QUAKER ROAD, QUEENSSIJRY, NEW YORK 12804 (518) 745-4476 (518) 745.4477 Funeral Director l �(`Ic IvL Name � C111GjS el `," Case# 30 Date Of Cremation � 3 -� U Time Cremation Started Time Cremation Completed lo,'vb Type of Container ( cirri "P Remarks 3v ------------ ----------------- CvaL 1 C1, UU /�i 30 Town of Queensbury Pine View Cemetery and Crematorium 21 Quaker Road, Queensbury,New York, 12MM Cemetery Office:(518)745-4476, Crematorium: (518)745- 477 Authorization to Cremate The urdersigrnad requests and aurhonmes Pine View Crematorium,in accordance with and subject to Ks Rules and Regulations to cremate the remains of: Thomas Fellman M (Name) _ -- (SOX) 1056 Dix Kingsbury NY 12839 (Street)O l/18/2 0 0 7 (CM (State) (Zip Code) who died on day of 20 — Glens Falls Hospital Glens Falls NY at (glace) (Address) Name and addrda of near WkV relative or name of parson aulhormrng cremation: Caroline Gualtiere 869 Lawn Circle (Name) (Address) Relatlorrotnip to the deceased Daughter Name of Funeral Home Carleton Funeral Home, Inc. T_ IMPORTANT: 1 represent gut to the best of my ignowledge,the deceased(has)or(has no)paoarnalter,defihillive r or any other betWy operated device in his or her body. (Ctrde One) I certify that I have full power and authorization to arrange for the crerrnaticn of the remains and to direct the disposition of the cremated remains,that any personal possessions have either been removed or rney be destroyed,and agree to protect,dekrd and save ham*m Pine View Crenvelorlum from any and all cMk. and demands for lass or damages which may be made soninat them by resso of or connected with the of said remains as directed,wh(eRw such deft o�r demands are or are trot wholly L"WHOWNfalse or i (Address) (Signature and Address Relative or LOW Representative) signed on this date: DC/1'� / 2- ©l, Disposition of Cremated Remains I hereby direct Pine View Crematorium to dispose of the c rernated remains es failorvs: Mail to Other arrangerna nls-Planes,specify: if pulverbotion of cremated remains Is requested,check hers XX Revision:January 1,2006